The relationship between context and health inequalities: Europe and Portugal as case studies
Abstract
As desigualdades socioeconómicas na saúde têm sido observadas há séculos por todo o mundo. Décadas de investigação identificaram múltiplos fatores que determinam estas desigualdades, como educação ou emprego. Recentemente, o foco da investigação sobre desigualdades em saúde mudou de determinantes individuais para determinantes contextuais, como as características físicas e sociais do ambiente. No entanto, a investigação sobre os determinantes contextuais depara-se com a ausência de uma base teórica sobre como estes determinantes influenciam a saúde. Portugal, sendo um dos países Europeus mais desiguais, tanto em rendimento como em saúde, é um caso de estudo interessante para o estudo das desigualdades em saúde. Esta tese procura contribuir para a compreensão do impacto dos determinantes contextuais na saúde e na sua distribuição, utilizando Portugal e a Europa como casos de estudo. Para cumprir este objetivo, foram selecionados três determinantes contextuais – capital social, regimes de bem-estar e alterações macroeconómicas – e os seus efeitos sobre a saúde e sobre as desigualdades em saúde foram explorados. Fora utilizados dados transversais do European Social Survey para analisar a associação entre capital social e saúde auto-declarada em países Europeus entre 2002 e 2012. A mesma base de dados foi utilizada para analisar a associação entre a mobilidade social e saúde auto-declarada em seis tipos de regimes de bem-estar Europeus. Estas análises utilizaram regressões logísticas multinível. Para analisar evidência sobre desigualdades socioeconómicas na saúde em Portugal depois de 2000 foi efetuada uma revisão sistemática da literatura. Dados transversais do European Union Survey on Income and Living Conditions foram utilizados para analisar alterações da desigualdade nas limitações em saúde em Portugal entre 2004 e 2014, tendo em conta as alterações macroeconómicas no País. Nesta análise, foram utilizados o índice de concentração e regressões logísticas múltiplas. O capital social contextual estava associado com pior saúde auto-declarada em indivíduos com pouca confiança interpessoal, influenciando assim a distribuição da saúde. Regimes de bem-estar Europeus estavam associados com a magnitude do impacto da mobilidade social na saúde. A revisão sistemática mostrou que o estudo dos determinantes contextuais em Portugal ainda é incomum. Alterações macroeconómicas em Portugal influenciaram a saúde e a sua distribuição na última década. Com base nestes resultados, foi delineado um quadro conceptual sobre a influência do contexto na saúde da população e na sua distribuição. O quadro conceptual distingue claramente entre um mecanismo que influencia a saúde da população e outro que influencia a sua distribuição. Este quadro pode ser utilizado como base de análises futuras para clarificar os mecanismos pelos quais o contexto influencia a saúde e as desigualdades em saúde. Pode também apoiar decisões sobre políticas que procurem influenciar a saúde da população e reduzir as desigualdades em saúde. Apesar das suas limitações, este trabalho produz evidência sobre os determinantes socioeconómicos da saúde em Portugal e sobre o impacto que o contexto pode ter nestes determinantes e nas desigualdades em saúde. O quadro conceptual proposto poderá avançar o debate sobre a influência do contexto na saúde e na sua distribuição.
Full text
Uni e sidade No a de Lisboa
Ins i u o de Higiene e Medicina T opical
The ela ionship be ween con ex and heal h
inequali ies: Eu ope and Po ugal as case s udies
Inês Campos Ma os
DISSERTAÇÃO APRESENTADA PARA CUMPRIMENTO DOS REQUISITOS
NECESSÁRIOS À OBTENÇÃO DO GRAU DE DOUTOR EM SAÚDE
INTERNACIONAL, ESPECIALIDADE DE POLÍTICAS DE SAÚDE E
DESENVOLVIMENTO
JUNHO, 2017
Uni e sidade No a de Lisboa
Ins i u o de Higiene e Medicina T opical
The ela ionship be ween con ex and heal h
inequali ies: Eu ope and Po ugal as case s udies
Au o a: Inês Fe ei a Pi a de Campos Ma os
O ien ado : P o esso Giuliano Russo
Coo ien ado a: P o esso a Luzia Gonçal es
Disse ação ap esen ada pa a cump imen o dos equisi os necessá ios à ob enção do
g au de Dou o a em Saúde In e nacional, especialidade de Polí icas de Saúde e
Desen ol imen o, de aco do com o Regulamen o Ge al do 3.º Ciclo de Es udos
Supe io es Conducen es à Ob enção do G au de Dou o pelo Ins i u o de Higiene e
Medicina T opical/Uni e sidade No a de Lisboa (n.º 474/2012) publicado no Diá io da
República, 2.ª sé ie, n.º 223 de 19 de no emb o de 2012.
Apoio inancei o:
Subsídio pa a In e nos Dou o andos da Fundação pa a a Ciência e a Tecnologia
Re e ência SFRH/SINTD/94891/2013
Bolsa Fulb igh pa a In es igação em Saúde Pública da Comissão Fulb igh
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
i
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
ii
Publica ions om his disse a ion
Campos-Ma os I, Kawachi I. Social mobili y and heal h in Eu opean coun ies: does
wel a e egime ype ma e ? Social Science and Medicine. 2015;142:241-248 DOI:
h ps://doi.o g/10.1016/j.socscimed.2015.08.035
Campos-Ma os I, Sub amanian SV, Kawachi I. The ‘da k side’ o social capi al: us
and sel - a ed heal h in Eu opean coun ies. Eu opean Jou nal o Public Heal h.
2016;26(1):90-95. DOI: h p://dx.doi.o g/10.1093/eu pub/ck 089
Campos-Ma os I, Russo G, Pe elman J. Connec ing he do s on heal h inequali ies – a
sys ema ic e iew on he social de e minan s o heal h in Po ugal. In e na ional
Jou nal o Equi y in Heal h. 2016;15(1):15-26. DOI: 10.1186/s12939-016-0314-z
Campos-Ma os I, Russo G, Gonçal es L. Shi ing de e minan s o heal h inequali ies in
uns able imes: Po ugal as a case s udy. Eu opean Jou nal o Public Heal h. 2017.
DOI: h ps://dx.doi.o g/10.1093/eu pub/ckx080
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
iii
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
i
Acknowledgemen s
To my supe iso s – Luzia Gonçal es and Giuliano Russo – and o he people who
supe ised my wo k on his hesis – I. Kawachi, S.V. Sub amanian, and J. Pe elman. To
colleagues and bosses in o he a eas o my li e – in pa icula Jo ge Nunes and Ped o
Se ano. To e e yone who ook he ime o each me, I am deeply g a e ul.
To my iends, who mos ly dis ac ed me om my wo k, and o whom I p o oundly
hank o ha .
To my amily, in pa icula o my pa en s, who ha e always suppo ed me. My lo e,
g a i ude, and admi a ion o you is ne e -ending.
To Ch is. Thanks o all he chocola e, pa ience, and an ing.
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
i
P e en ion is he hea o Public Heal h. Bu equi y is i s soul.
D Ma ga e Chan
Opening add ess a he Execu i e Boa d special session on WHO e o m, No embe
2011, when she was Di ec o -Gene al o he Wo ld Heal h O ganiza ion
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
ii
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
xi
3.1.4. Shi ing De e minan s o Heal h Inequali ies in Po ugal ...................... 107
3.1.5. Summa y ................................................................................................ 109
3.2. Limi a ions ....................................................................................................... 111
3.3. The E ec o Con ex on Heal h and on Heal h Dis ibu ion .......................... 113
3.3.1. Fi s Mechanism: Changes in O e all Heal h ........................................ 113
3.3.2. Second Mechanism: Changes in Heal h Dis ibu ion ............................ 115
3.3.3. Concep ual F amewo k .......................................................................... 117
3.3.4 Summa y ................................................................................................. 121
3.4. Applica ion o he Concep ual F amewo k ...................................................... 122
3.4.1. Social Capi al and Heal h in Eu opean Coun ies .................................. 122
3.4.2. Social Mobili y and Heal h in Eu opean Wel a e Regimes ................... 123
3.4.3. Shi ing De e minan s o Heal h Inequali ies in Po ugal ...................... 125
3.4.4. Summa y ................................................................................................ 127
3.5. Con ibu ion o Policy and Resea ch ............................................................... 129
3.5.1. Rega ding Heal h Inequali ies ................................................................ 129
3.5.2. Rega ding Eu ope .................................................................................. 130
3.5.3. Rega ding Po ugal ................................................................................ 131
3.5.4. Summa y ................................................................................................ 132
3.6. Conclusions ...................................................................................................... 133
3.7. Discussion and Conclusion Re e ences ........................................................... 135
4. APPENDICES ........................................................................................................ 141
4.1. Appendix 1: Illus a ion o how changes in heal h inequali ies a ec absolu e
and ela i e measu es – a hypo he ical example ..................................................... 143
4.2. Appendix 2: Online supplemen a y da a om he i s publica ion ................. 145
4.3. Appendix 3: Online supplemen a y da a om he hi d publica ion ............... 151
4.4. Appendix 4: Online supplemen a y da a om he ou h publica ion ............. 171
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
x
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
x i
Lis o Figu es
Figu e 1. Wide De e minan s o Heal h Model, by Dahlg en and Whi ehead ........... 3
Figu e 2. WHO's Commission on he Social De e minan s o Heal h F amewo k ..... 5
Figu e 3. A amewo k o elucida ing he pa hways om he social con ex o heal h
ou comes and o in oducing policy in e en ions ..................................................... 29
Figu e 4. Flow o in o ma ion h ough he di e en phases o a sys ema ic e iew
p oposed by he PRISMA s a emen ............................................................................ 46
Figu e 5. Hypo he ical concen a ion cu e ................................................................. 49
Figu e 6. Fi s mechanism: changes in o e all heal h ................................................. 114
Figu e 7. Second mechanism: changes in heal h dis ibu ion ...................................... 116
Figu e 8. The impac o con ex on heal h and heal h dis ibu ion: concep ual amewo k
..................................................................................................................................... 117
Figu e 9. E ec o con ex ual social capi al on heal h dis ibu ion ............................. 123
Figu e 10. E ec s o wel a e egimes and social mobili y on heal h and heal h
dis ibu ion ................................................................................................................... 125
Figu e 11. E ec s o socioeconomic changes on heal h and heal h dis ibu ion ......... 127
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
x ii
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
x iii
Lis o Tables
Table 1. Wel a e egime ypes, hei main cha ac e is ics, and example coun ies ........ 23
Table 2. Summa y o disse a ion publica ions, de e minan s es ed, geog aphic con ex ,
ime pe iod, and main indings .................................................................................... 110
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
xix
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
xx
Lis o Abb e ia ions
BMI Body Mass Index
CC Concen a ion Cu e
CHD Co ona y Hea Disease
CIx Concen a ion Index
CSDH Commission on he Social De e minan s o Heal h
DFID Depa men o In e na ional De elopmen
ESS Eu opean Social Su ey
EU Eu opean Union
EU-SILC Eu opean Su ey on Income and Li ing Condi ions
GDP G oss Domes ic P oduc
HI Heal h Inequali ies
HIV Human Immunode iciency Vi us
ILO In e na ional Labou O ganiza ion
OR Odds Ra io
PRISMA P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses
RII Rela i e Index o Inequali y
SAH Sel Assessed Heal h
SDH Social De e minan s o Heal h
SES Socioeconomic S a us
SII Slope Index o Inequali y
SR Sys ema ic Re iew
UK Uni ed Kingdom
US Uni ed S a es
USSR Union o So ie Socialis Republics
WHO Wo ld Heal h O ganisa ion
Disse ação pa a a ob enção do g au de Dou o em Saúde In e nacional
Inês Campos Ma os, Junho de 2017
xxi
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
1
1. In oduc ion
1.1. The S udy o Heal h Inequali ies
1.1.1. Fou Decades o Poli ics and Resea ch on Heal h Inequali ies
Academia has a long adi ion o seeing i sel as an au onomous body, ee om
ideological hough and om social and poli ical con ex (1). Howe e , academic
wo k is no done in isola ion om i s su ounding wo ld. The s o y o how academic
knowledge abou heal h inequali ies (HI) and he social de e minan s o heal h (SDH)
has e ol ed in he pas ou decades is a e lec ion o how his knowledge and
dominan poli ical hough go hand in hand, some imes one pushing o wa d mo e
igo ously.
The connec ion be ween socioeconomic de e minan s and heal h has been known o
cen u ies, bu he e has been a g owing in e es in he subjec in he las ou decades.
In Eu ope, his poli ical and academic in e es was shaped by a ew landma k e en s.
The i s poli ical landma k was he publica ion o he Black Repo in he Uni ed
Kingdom (UK) in 1980 (2). This epo was se up by a Labou Sec e a y o S a e o
Heal h who was conce ned abou he dimension o mo ali y inequali ies be ween
social classes (3). The epo ound ha , despi e h ee decades o a Na ional Heal h
Se ice, HI s ill exis ed and could la gely be explained by di e ences in ma e ial
condi ions be ween social classes (2). Bu he inal documen was epo ed o a
Conse a i e go e nmen , elec ed in 1979 unde he commi men o educe public
spending, who dismissed i and ailed o p ope ly publish i (3). Despi e his, he
epo played a pi o al ole in se ing he esea ch agenda o wo decades a e i was
published (3, 4).
The indings o he Black Repo we e in o med by a body o academic wo k
published in he yea s be o e. P obably he mos no iceable indings came om he
Whi ehall s udy (3), a longi udinal s udy o ci il se an s wo king in London ha
s a ed in 1967 o analyse he ‘powe o isk ac o s and indica o s o co ona y hea
disease (CHD) o p edic mo ali y’ (p. 1165). The Whi ehall s udy showed a clea
in e se ela ionship be ween g ade o employmen and CHD mo ali y ha pe sis ed
e e a e con olling o a wide ange o ca dio ascula isk ac o s (5). As one o he
au ho s o he o iginal s udy, Si Michael Ma mo , la e commen ed in an in e iew,
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
2
his was unexpec ed, as a he ime common sense sugges ed ha hea disease was
mo e common in people wi h highe -g ade, mo e s ess ul jobs (6).
O e all, he Whi ehall s udies oge he wi h he Black Repo e lec ed a change in he
unde s anding o he de e minan s o heal h. The UK was seen as a success in e ms
o popula ion heal h imp o emen , wi h ex ensi e s a e-p o ided social suppo and
uni e sal heal hca e p o ision. These analyses showed ha , o e and abo e he di ec
e ec o he mos basic de e minan s o heal h – such as die o heal hca e – s ong
social o ces ope a ed o c ea e a heal h g adien , e en among people who had access
o all essen ial li ing condi ions.
The posi ioning o HI and SDH in he esea ch agenda led o a p oli e a ion o
empi ical analyses in he yea s ensuing he publica ion o he Black Repo . In 1991,
Dahlg en and Whi ehead p oposed he ‘Wide De e minan s o Heal h Model’,
p obably he mos widely known and used amewo k on his opic (7) ( igu e 1). This
model desc ibes he main in luences o heal h, buil in laye s, one on op o he o he .
The s uc u al en i onmen is he o e a ching laye , which includes ‘gene al socio-
economic, cul u al and en i onmen al condi ions’. This is ollowed by a laye o
li ing and wo king condi ions, which includes ac o s like employmen and
educa ion. The nex wo laye s e e o suppo om social ne wo ks and indi idual
li es yle, espec i ely. Finally, he cen al laye is made o indi idual unchangeable
ac o s, such as age and sex. This model p o ed use ul in p esen ing he main
de e minan s o heal h o b oad audiences, and was g oundb eaking when i was i s
published, as i highligh ed he impo ance o b oade socioeconomic ac o s in he
p oduc ion o heal h. I also emphasized he cumula i e na u e o he de e minan s o
heal h and p o ided a amewo k upon which o conside policy op ions, as each laye
can be ansla ed in o a le el o policy in e en ion.
In 1997, a e eigh een yea s o conse a i e ule, he UK elec ed a Labou
go e nmen . This new go e nmen was elec ed wi h a s ong commi men o educe
social inequali ies, and quickly commissioned a epo o ‘ e iew and summa ise
inequali ies in heal h in England and o iden i y p io i y a eas o he de elopmen o
policies o educe hem’ (8: p.5). This was ma e ialized wi h he publica ion o he
Acheson Inqui y in 1998, which e ealed a wide ange o HI h oughou he li e-
cou se, some e en inc easing o e he p e ious decades. The epo clea ly s a ed ha
HI we e a consequence o socioeconomic ac o s, and as such could only be ackled
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
9
esponsible o he dis ibu ion o indi idual de e minan s o heal h, such as income o
educa ion ( igu e 2) (12).
Bu how does con ex in luence heal h and i s dis ibu ion? The answe o his
ques ion has been unde mined by a numbe o challenges acing his body o
li e a u e. As an eme ging opic, one o he main issues has been he he e ogeneous
concep ualiza ion o con ex (14). Di e en au ho s ha e used di e en de ini ions o
wha con ex is, including a wha physical o geog aphical le el i ope a es –
household, neighbou hood o coun y will likely all in luence heal h, bu p obably in
di e en ways. Dide ichsen e al. (28), o example, de ine con ex as a ‘ca ch-all
ph ase used o e e o he spec um o ac o s in socie y ha canno be di ec ly
measu ed a he indi idual le el’ (p. 19), encompassing he ‘s uc u e, cul u e and
unc ion o a social sys em’ (p. 19). This ague de ini ion highligh s he di icul y o
homogenise he concep . Po a’s dic iona y o Epidemiology (33), on he o he hand,
de ines con ex as ‘ he loca ion o a pe son by ime and place’, e e ing o bo h
‘geog aphical loca ion and o g oup membe ship’ (p. 58). This de ini ion b ings o
ocus wo componen s o con ex ha a e commonly iden i ied: he physical and he
social en i onmen . These en i onmen s can no only in luence heal h, bu may also
in luence each o he (34). Fo example, he ex en o physical space a communi y has
a ailable will in luence how i s indi iduals in e ac . This dis inc ion b ings o ligh
ha , by being physical o social, con ex is no es ic ed o a geog aphical de ini ion;
con ex ual cha ac e is ics can be de ined wi hin a ne wo k o pee s who in e ac
exclusi ely online, bu who none heless sha e social no ms ha shape hei elemen s’
heal h.
Ano he common concep ualiza ion o con ex dis inguishes be ween ‘composi ional’
and ‘con ex ual’ e ec s. This dis inc ion a ose om geog aphical analyses ha hink
o place e ec s as a consequence o he cha ac e is ics o he people who eside in a
ce ain place (‘composi ional’) and o he cha ac e is ics o he place i sel
(‘con ex ual’). Howe e , as Macin y e e al. (14) and F ohlich e al. (21) a gue, his
dis inc ion is no necessa ily use ul no co ec . In ac , he e a e complex
in e dependencies be ween people (‘composi ion’) and places (‘con ex ’), as
indi iduals a e no placed a andom whe e hey li e o whe e hey wo k. As
Macin y e (35) pu i : ‘people make places and places make people’ (p. 12).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
10
Ano he ac o hampe ing he app op ia e analysis o con ex ual in luences on heal h
is he lack o clea heo izing abou he mechanisms by which con ex ope a es (14).
This leads o a sea ch o con ex ual de e minan s o heal h ha has no basis on a
s ong heo y o how hese de e minan s ope a e. As Mi chell e al. (36) commen ,
‘lack o heo y has o en esul ed in a choice o a iables wi h which o cha ac e ize
an a ea which is guided mo e by wha is a ailable ‘o he shel ’ han by ca e ul
heo e ical conside a ion’ (p. 68). As a esul o unclea de ini ion and heo izing,
measu emen o con ex has been, in he leas , he e ogeneous.
This has also dismissed impo an ques ions such as which spa ial o ime scales a e
app op ia e. Indeed, con ex ual in luences can be measu ed as cha ac e is ics o a
s ee , neighbou hood, ci y, o coun y, jus o name a ew. Pa hways ha link hese
cha ac e is ics o popula ion heal h and HI will di e acco ding o he geog aphical
scale hey a e being measu ed a . Fo example, while a uni e sal heal hca e policy
migh be a good measu e o heal hca e access, i does no ake in o accoun egional
inequali ies in he dis ibu ion o heal hca e se ices, which can only be de ec ed wi h
a smalle scale analysis. On he o he hand, ideological iews such as acism and
o he o ms o disc imina ion may no be de ec ed a such a small scale, bu
none heless be p ominen in he coun y and ha e an impo an e ec on he heal h o
ha popula ion (37). Time scales a e also o en imes dismissed: mos analyses
measu e con ex ual exposu e and heal h ou come a he same momen in ime, bu his
is o en implausible, as exposu es can ake ime o ha e an e ec . Fo example, ai
pollu ion may ake decades o ha e an impac on adul mo ali y, and his biological
plausibili y mus be aken in o accoun (14).
Finally, as desc ibed in he i s sec ion, con ex has also been pushed aside om
esea ch as a consequence o dominan poli ical iews. As Ma ga e Tha che
amously pu i , “ he e is no such hing as socie y” (38).
Unclea de ini ion, ope a ionaliza ion, and heo izing ha e conside ably complica ed
he cons uc ion o a cohe en heo y on he in luence o con ex on heal h and HI.
This has led o impo an c i iques, e en compa isons wi h medie al medical heo y –
Slogge and Joshi (39) called he con ex ual in luence a ‘social miasma’ (p. 1473).
Howe e , despi e he weaknesses in he cu en e idence on his opic, and he
c i iques o i s exis ence as an issue a all, esea che s would end o ag ee ha whe e
people li e ma e s o hei heal h (40). In a b ie e iew o he e idence, Macin y e
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
11
e al. (14) conclude ha ‘ a he han he e being one single, uni e sal ‘a ea e ec on
heal h’ he e appea o be some a ea e ec s on some heal h ou comes, in some
popula ion g oups, and in some ypes o a eas’ (p. 128). This conclusion sugges s ha
con ex can some imes ha e li le impac on o e all popula ion heal h, and a
emendous impac on i s dis ibu ion be ween popula ion g oups, and hence on HI.
Thus, con ex appea s o ha e an impo an in luence on heal h and i s dis ibu ion
wi hin a socie y, bu cu en knowledge is conside ably hampe ed by a numbe o
issues, such as he e ogeneous concep ualiza ion and measu emen . Addi ionally,
con ex can ha e di e en e ec s depending on he indi idual, place, and ime. This
di e en ial e ec sugges s ha no only i is necessa y o ake con ex in o accoun
when s udying HI, bu ha i may be key o hei unde s anding. An app op ia e
heo e ical amewo k ha summa izes hese ela ionships would p o ide he much
needed basis on which empi ical analysis could build e idence.
1.1.4. Summa y
Resea ch in HI and he SDH has g own exponen ially in Eu ope since he 1980s,
when poli ical in e es in he opic i s eme ged. Academic and poli ical in e es in HI
e ol ed h ough his pe iod o ime, wi h a clea shi o ocus om indi idual
de e minan s, indi idualis ic me hodology and ‘ isky beha iou s’, o social p ocesses
and con ex as de e minan s o HI. This shi is e lec ed no only on dominan
poli ical hough o indus ialized socie ies, bu also on dominan academic hough .
This pa allel cou se shows how he academic discou se is no sepa a e om he wo ld
ha su ounds i , as he iews o esea che s can be shaped by dominan no ma i e
iews o he socie y hey a e in.
The indi idualis app oach ha has domina ed esea ch on HI has cons ained
knowledge and hinde ed he c ea ion o policies ha e ec i ely educe hem. This has
happened because issues o he e ogeneous concep ualiza ion, measu emen , and
heo e ical de ini ion ha e unde mined he s udy o con ex ual de e minan s, which
has opened he ield o conside able c i ique. Howe e , con ex ual de e minan s a e
una oidable, pa icula ly when explo ing HI, namely o measu emen and concep ual
issues. Ul ima ely, i is likely ha con ex has a complex di e en ial e ec ha
in e ac s wi h indi idual cha ac e is ics. This makes con ex key in he unde s anding
o HI.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
12
The no ion ha no all de e minan s o heal h a e bes concep ualized a he indi idual
le el has been called he new pa adigm o public heal h. As a new idea, i is s ill in
de eloping s age, and would bene i g ea ly om a solid heo e ical basis ha would
allow build-up o knowledge and adequa e policy choices.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
13
1.2. Measu emen o Heal h Inequali ies
1.2.1. Which De e minan s?
Fo a long ime and ac oss many coun ies, he poo ha e had wo se heal h and
sho e li es han he weal hy (41). This consis ency is seen ega dless o he majo
causes o dea h in socie y: i is ue when communicable diseases a e he main kille s,
and i is ue o non-communicable diseases (42). I is seen h ough he li e cou se,
om ges a ion o bi h, childhood, adolescence, adul hood and old age (43). I is seen
using a numbe o di e en s a is ical me hods and measu emen s, and i is seen by a
numbe o indi idual SES measu es, like income, educa ion o occupa ion (44). Bu
he s udy o con ex ual de e minan s has aised bo h concep ual and me hodological
ques ions ha canno be answe ed by adi ional iews o indi idual cha ac e is ics
and adi ional s a is ical me hods alone.
Concep ually, ecognizing con ex ual e ec s on indi idual heal h implies a shi in he
unde s anding o how isk ac o s ope a e. In adi ional epidemiology, indi idual
cha ac e is ics a e iden i ied as causes o isk ac o s o ill heal h, implying ha
in e en ions should be ocused on he indi idual. Some c i iques o his app oach
claim ha an exclusi e ocus on he indi idual can lead o coun e p oduc i e
p ocesses o ic im blaming (45). The new pa adigm o con ex ual e ec s on heal h
ecognizes ha he con ex can be, in and o i sel , a de e minan o heal h.
Addi ionally, he acknowledgemen o con ex as ha ing an in luence on heal h also
implies ha indi idual cha ac e is ics mus be amed by he con ex hey a e in. In
his sense, ha ing a ce ain amoun o money ma e s no only in absolu e e ms, bu
also conside ing he a e age weal h o e e yone else, i.e., wha you ha e ma e s, bu
wha o he s a ound you ha e ma e s oo. This implies ha HI can be c ea ed, in pa ,
o psychosocial mechanisms. Indeed, a no iceable inding in HI esea ch has been ha
HI do no occu in a h eshold e ec . Sys ema ic di e ences a e no seen jus below a
ce ain poin o income, weal h o occupa ional ank. Ra he , he e is a socioeconomic
g adien in heal h, in which he poo es ha e wo se heal h han he ones who ea n an
a e age income, who in u n ha e wo se heal h han he iches (41). This g adien is
seen o all SES de e minan s: inancial esou ces, educa ion and occupa ion. This
g adien shows ha socioeconomic de e minan s do no in luence heal h only because
hey p o ide access o essen ial esou ces, o he wise he e would be no di e ence
once hose essen ial esou ces we e p esen (44). Ra he , he e a e o he e ec s a
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
14
wo k h ough he social spec um ha p oduce sys ema ic di e ences in heal h
ou comes. These e ec s a e a consequence o psychosocial mechanisms.
While ma e ial condi ions a e widely ecognized and impo an o he heal h
g adien , as hey a e di ec ly ela ed o access o heal h p omo ing esou ces, such as
quali y ood and housing, ex ensi e esea ch has shown ha ad e se social condi ions
can di ec ly lead o ad e se biological e ec s, ega dless o access o esou ces (46).
This iew helps unde s and he socioeconomic heal h g adien . Wi hin a s uc u e o a
socie y, e e yone is benea h someone else by some measu e – be i money, p es ige,
cul u al capi al, o o he s. This social hie a chy can c ea e s ess esponses, as being
o a lowe social s a us may lead o eelings o inadequacy and lack o con ol (47).
As such, since he e is always someone be e o , e e yone su e s he consequences
o his g adien , no only he poo es . These s ess esponses ha e a di ec impac on
biological unc ioning, and can lead o mo e heal h damaging beha iou , such as
d inking and smoking. This leads o a heal h g adien ha a ec s e e yone, e en a e
basic ma e ial condi ions o a heal hy li e a e sa is ied. No iceably, a he han being
opposi e explana ions, ma e ial and psychosocial mechanisms ac oge he o help
explain he socioeconomic heal h g adien (44).
Psychosocial explana ions highligh ha , u he han being a ques ion o absolu e
po e y, HI a e also a ques ion o ela i e dep i a ion. The in e na ional glossa y o
po e y de ines ela i e po e y as he ‘absence o inadequacy o hose die s,
ameni ies, s anda ds, se ices and ac i i ies which a e common o cus oma y in
socie y’ (48: p. 169). This no ion o po e y implies ha i can be a socially de ined
concep , measu ed wi hin he g oup he indi idual is in, as i depends on wha is
‘cus oma y in socie y’.
The heal h g adien and psychosocial explana ions show ha he c ea ion o HI is
complex and a p oduc o mul iple de e minan s ope a ing a he same ime.
Impo an ly, hese de e minan s occu a bo h he indi idual and con ex ual le el
simul aneously, and nei he should be igno ed.
a) Indi idual De e minan s
His o ically, income, educa ion, occupa ion and employmen ha e domina ed he
analysis o HI as de e minan s o indi idual SES. These de e minan s a e o en used
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
15
in e changeably, bu esea ch has shown ha his is no necessa ily co ec , as hey
can e lec di e en unde lying causal p ocesses (49).
i. Educa ion
Educa ion is p obably he mos commonly used measu e o SES and has ex ensi ely
been ela ed o a ious heal h ou comes. Compa a i e analyses be ween Eu opean
coun ies show s ong associa ions o educa ion wi h cause-speci ic mo ali y (50),
sel -assessed heal h (SAH) (51), limi ing long-s anding illness (52), ch onic
condi ions (53), smoking (54, 55) and obesi y (56). As a measu e o SES, educa ion
has a numbe o impo an ad an ages: i is easy o measu e, shows high esponse
a es in su eys, is ai ly compa able ac oss coun ies, applicable o bo h wo king and
non-wo king indi iduals, ends o emain s able h ough li e, and is no likely o be
a ec ed by e e se causa ion, since i is usually de e mined in young adul hood and
emains s able h oughou li e (57). Howe e , e e se causa ion canno be comple ely
excluded, since a heal hy li e expec ancy migh induce highe in es men s in
educa ion and ill child en migh be less able o comple e educa ion (58). None heless,
analyses o compulso y schooling laws in he US and Eu ope, which ‘ o ce’ mos
people in o educa ion, ega dless o hei heal h p ospec s, sugges ha educa ion
causes be e heal h, despi e he opposi e also being ue (59-61).
Se e al mechanisms explain he pa hway linking educa ion o heal h. The e ec
seems o be media ed in pa by income and occupa ion, al hough analyses show an
educa ional g adien e en a e con olling o hese ac o s (58). The emaining
heal h di e ences can be s ongly explained by beha iou al ac o s, which in u n
seem o be a consequence o be e in o ma ion and be e cogni i e abili ies, which
a ec s he abili y o p ocess in o ma ion ega ding heal hy beha iou s and disease
managemen (62). P e e ences also seem o play a pa , as hey a y sys ema ically
ac oss educa ional g oups (62). Finally, educa ion can also p o ide an indi idual wi h
a social ne wo k o simila ly educa ed pee s, which can ha e subs an ial heal h
bene i s (41).
ii. Financial esou ces
Financial esou ces, such as income o weal h, a e also s ongly co ela ed wi h
heal h, independen ly o educa ion. They can ha e an impac on heal h o he ex en
ha hey allow indi iduals o access heal h-p oducing esou ces, such as heal hca e o
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
16
be e li ing condi ions. Howe e , assessing causali y is di icul , since heal h
s ongly inc eases one’s abili y o ea n money and se e al con ounding ac o s – such
as educa ion o p e e ences – migh de e mine bo h be e heal h and be e income.
Whe eas he e ec o heal h on income has been ex ensi ely shown in a numbe o
socie ies, he e ec o income on heal h emains mo e o an ‘open ques ion’ (41, 58).
Unlike educa ion, inancial esou ces can be mo e di icul o measu e, as people may
no be as happy o sha e his in o ma ion, he e a e many componen s in ol ed
(income, weal h, sa ings, p ope y, e c.), and compa abili y can be hampe ed by
di e en cu encies and di e ences in cu ency alue, o example. None heless,
income- ela ed heal h g adien s ha e been shown o SAH (63, 64), unc ional
limi a ions (64, 65) and smoking (55) in Eu opean coun ies.
iii. Employmen
Employmen , o lack o i , is cen al o mos adul s’ li e and has been associa ed wi h
heal h in a numbe o se ings. This associa ion is no su p ising. Fi s o all,
employmen p o ides income, which is essen ial o access o basic goods.
Unemploymen can lead no only o inancial s ain, bu also unce ain y abou he
u u e. This leads o a second mechanism: s ess. Unemploymen , wi h he unce ain y
i b ings, leads o a eeling o lack o con ol, which has been ex ensi ely associa ed
wi h ad e se heal h ou comes (66). Employmen also p o ides psychological bene i s
– like p o iding a s uc u e o he day, sel -es eem, s a us and a sense o con ibu ion
o a collec i e cause – ha a e absen in unemploymen (67). Oppo uni ies o
socialize a e also mo e common when one is employed, and social suppo and
in eg a ion ha e ex ensi ely been linked o heal h (68). Finally, unemployed
indi iduals seem o ha e an inc eased isk o heal h-damaging beha iou s, such as
smoking and d inking (69). This migh occu because people who d ink and smoke
a e mo e likely o become unemployed, because people who become unemployed
d ink and smoke mo e o deal wi h hei s ess ul si ua ion, as a consequence o a
common causal ac o , o a combina ion o any o hese. Rega dless, employmen is a
majo ac o in HI among wo king-age adul s.
Analyses in Eu opean coun ies ha e shown ha unemploymen is associa ed wi h
wo se SAH (63), ch onic heal h condi ions (70) and mo ali y (71).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
17
i . Occupa ion
The In e na ional Labou O ganisa ion (ILO) (72) de ines occupa ion as ‘a se o jobs
whose main asks and du ies a e cha ac e ised by a high deg ee o simila i y’ (p. 1).
Acco dingly, occupa ional g ades a e usually classi ied acco ding o asks and
esponsibili ies in ol ed. P obably he mos commonly used classi ica ion is ILO’s
In e na ional S anda d Classi ica ion o Occupa ions, which de ines en majo
occupa ional g oups, om elemen a y occupa ions o manage s, de ined in e ms o
skill le el and specialisa ion equi ed o each occupa ion (73). O he classi ica ions,
such as manual and non-manual (53), adminis a o s, p o essionals, execu i es and
cle ks (74) o whi e colla and blue colla (75) a e some imes used, bu all e lec
di e en deg ees o skills ha a e equi ed o he job.
Occupa ional g ade has been s ongly associa ed wi h heal h ou comes. In Eu opean
coun ies, i has been associa ed wi h o e all mo ali y (53, 76), s oke and ischaemic
hea disease mo ali y (77), in an mo ali y (78), child heal h (78), SAH, long e m
limi a ions and ch onic condi ions (79). The Whi ehall s udies a e one o he mos
impo an con ibu ions o he unde s anding o his ela ionship. These s udies
showed ha people in highe anks had a s onge sense o con ol o e hei heal h,
hei jobs and hei li es (74), which is s ongly associa ed wi h be e heal h (66).
Howe e , occupa ion can also e lec an indi idual’s place in socie y, o a g ea e
ex en han inancial esou ces, educa ion o employmen do. Ha ing an occupa ion
will usually g an adequa e ea nings and a ce ain deg ee o job secu i y, so he heal h
di e ences ha emain can also be explained by he e ec o social s anding ( ank)
and subjec i e eelings owa ds one’s posi ion in socie y (59). In ac , a numbe o
au ho s ha e used occupa ion as a ma ke o ‘social class’ (80-82), possibly based on
he unde s anding ha occupa ion e lec s mo e han jus skill le els and
specialisa ion.
. Social Mobili y
The SES o an indi idual can ha e an impac on hei heal h a any gi en ime and he
mo emen be ween di e en social s a a can oo. Social mobili y is he p ocess o
mo ing be ween social s a a, ei he be ween gene a ions (pa en s and child en) o
wi hin he li e-cou se o he indi idual (in e - and in agene a ional social mobili y,
espec i ely).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
18
Social mobili y has been associa ed wi h heal h in a a ie y o con ex s (83, 84), bu
he way i ope a es can be di icul o ease ou . One possibili y is ha i is an
accumula ion e ec . Powe e al. (85), o example, showed ha in a bi h coho om
he UK, he accumula ion o un a ou able social ci cums ances was mo e impo an
han social mobili y pe se in de e mining adul heal h. This means ha , when
compa ing wo people wi h he same SES, one o whom ‘mo es down’ he social
ladde and ano he who emains s able, he i s will ha e wo se heal h ou comes.
Howe e , his is no a consequence o he downwa d social mo emen i sel , a he a
consequence o ha ing a lowe SES a a gi en momen in li e. Ano he explana ion
o he associa ion be ween social mobili y and heal h is an opposi e causal e ec :
ex ensi e empi ical analysis has shown a ‘heal h selec ion e ec ’ ha pushes people
who a e unheal hie down he social ladde (84, 86). This is no su p ising, as people
who a e ill can be less capable o s udy and wo k, hus educing hei po en ial
ea nings and social posi ion. Finally, some e idence also sugges s ha social
mo emen in and o i sel has some e ec on heal h (41, 83). Su p isingly, i is no
jus he downwa d mo emen ha seems o ha e a nega i e impac , bu also upwa d
mo emen , pa icula ly wi hin sho pe iods o ime, can also ha e a dele e ious e ec
(41). This unexpec ed e ec may be a consequence o an inc ease in unheal hy
beha iou (such as smoking mo e because one has mo e a ailable income), o o
physiological and beha iou al adap a ions o a di e en social se ing.
b) Con ex ual De e minan s
A mul i ude o con ex ual cha ac e is ics ha e been analysed in he li e a u e as
po en ial de e minan s o heal h. Building on he de ini ion o con ex ou lined in he
p e ious chap e , hese can be classi ied as physical o social de e minan s – wi h he
ca ea ha his is an o e simpli ied cha ac e isa ion, as physical and social con ex ual
cha ac e is ics o en in e ac wi h each o he .
Physical de e minan s can be hough o in e ms o na u al en i onmen – ai , wa e ,
noise, g een spaces – and o he buil en i onmen – houses, oads, in as uc u es,
and anspo sys ems. Ex ensi e esea ch has shown a s ong connec ion be ween he
buil en i onmen and heal h. Examples include impac s on men al heal h (87),
physical ac i i y (88), ea ing habi s (89), obesi y (90), and d inking (91). This
in luence can wo k h ough he a ailabili y o g een spaces ha allow people o ha e
a mo e physically ac i e li e, walkabili y o neighbou hoods ha help p o ide a sa e
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
25
s a us measu es and o he a iables ha impac mo ali y (124). Mo eo e , i s
capaci y o p edic mo ali y has become inc easingly mo e consis en be ween 1990
and 2002 in he US, possibly because o be e heal h ela ed in o ma ion (125). On
he o he hand, despi e i s s ong abili y o p edic mo ali y, his ela ion migh a y
be ween gende (126), age (127), and SES (128), possibly biasing esul s o HI
analyses. Howe e , SAH has alue on op o i s abili y o p edic mo ali y: i can be
seen as a mo e comp ehensi e measu e o heal h, which allows esponden s o weigh
di e en aspec s o hei own heal h and alue hem acco ding o hei own
p e e ences (129).
An inc easingly used al e na i e o SAH has been o use ‘heal h limi a ions’ as a
gene al measu e o heal h. This measu e is also based on a su ey ques ion ha asks
esponden s whe he hey a e limi ed in hei daily ac i i ies due o a heal h condi ion.
Possible answe s usually include ‘yes, se e ely limi ed’, ‘yes, somewha limi ed’, and
‘no’. Some au ho s conside his a ‘quasi-objec i e’ indica o , mo e accu a e han
SAH (65), and some ha e used i as a p oxy measu e o disabili y (130).
HI ha e been obse ed using bo h SAH and limi a ions as an ou come measu e (65).
These measu es ely on sel - epo ing, bu HI ha e also been obse ed in mo bidi y
indica o s ha a e based on objec i e measu emen s. Fo example, se e al cance s
(al hough no all) show a socioeconomic g adien , as does he su i al a e a e
cance diagnosis (78). Measu es o physical abili y also end o show a socioeconomic
g adien (131), as does Body Mass Index (BMI) (132) and he me abolic synd ome
(133), o men ion only a ew examples.
c) Heal h Rela ed Beha iou s
Acco ding o he Global Bu den o Disease S udy, he h ee isk ac o s ha mos
con ibu e o disease bu den in wes e n and cen al Eu ope a e high blood p essu e,
obacco smoking, and high BMI (134). These e lec he ou majo beha iou s
ela ed o non-communicable diseases: ea ing, d inking, smoking and exe cising.
These ou beha iou s ha e ex ensi ely shown a social pa e n, such ha people om
lowe SES end o show less compliance wi h die a y and exe cise ecommenda ions,
d ink mo e, and smoke mo e (135).
These heal h ela ed beha iou s occu wi hin social s uc u es and con ex s ha can
acili a e o hinde hem. Fo example, while ul ima ely smoking may be a ma e o
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
26
indi idual choice, ac o s such as he economic abili y o buy ciga e es, ha ing a
mo e o less s ess ul li e, and li ing in an en i onmen whe e social no ms suppo o
shame smoking beha iou , can all exe an in luence on ha inal ‘indi idual’
decision.
Ano he pa icula o m o heal h ela ed beha iou is heal h ca e use. As wi h o he
beha iou s, heal h ca e use and quali y a e also socially pa e ned (136). This can be
ela ed o ac o s like economic esou ces, access o in o ma ion o geog aphical
accessibili y. Howe e , a leas in a Eu opean con ex , heal h ca e is a om being
he mos impo an cause o HI and p obably con ibu es only sligh ly o hese
inequali ies (137).
1.2.3. Which Measu es?
Despi e being known o cen u ies, HI ha e no always been a unanimously accep ed
ac . The Black Repo dedica ed some o i s pages in o showing ha HI we e no a
p oduc o ma hema ical a e ac (4), bu i was s ill c i icized o he measu es i used
(138). In ac , he measu e one chooses o analyse HI can de e mine he esul o he
analysis, possibly e en leading o con adic ing esul s (138).
One o he mos commonly used me hods a e ange measu es, p obably he mos
simple and easy o in e p e . They compa e he heal h s a us o wo g oups o he
socioeconomic dis ibu ion. This is done by calcula ing absolu e o ela i e
di e ences (i.e., a ios). Fo example, i hal (0.5) o he poo es quin ile and a i h
(0.2) o he iches quin ile ha e diabe es, he absolu e di e ence is 30 pe cen age
poin s (0.5-0.2=0.3) and he a io is 2.5 (0.5/0.2=2.5).
While inequali y is summa ized in one alue, ange measu es show an incomple e
pic u e, as hey only compa e wo g oups (usually op and bo om). Inequali y
be ween hese wo g oups may emain he same, while he dis ibu ion wi hin he
middle g oups d ama ically changes (138). Ano he sho coming o hese measu es is
ha hey igno e he sizes o he g oups. This is impo an especially in compa a i e
analyses – ac oss ime o space – as wo simila esul s may e lec wo e y di e en
dis ibu ions. This is also an issue when socioeconomic g oups do no ha e a ixed
size, such as hose de ined by occupa ion o educa ion. A ange measu e o inequali y
may emain s able o e ime, bu i he g oup wi h mo e yea s o educa ion inc eases,
while he numbe o less educa ed dec ease, he dis ibu ion is clea ly di e en .
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
27
To o e come some o hese sho comings, eg ession-based measu es can be used. An
example is he Slope Index o Inequali y (SII): he eg ession coe icien ( he slope) o
a eg ession model o he heal h ou come on SES, o de ed by SES. I can be
in e p e ed as he absolu e e ec on he heal h ou come o mo ing om one SES
ca ego y o alue o he nex (139). Despi e i s simplici y, his measu e is sensi i e o
he popula ion mean o he heal h ou come, which limi s is compa abili y ac oss
popula ions and ime. The Rela i e Index o Inequali y (RII) o e comes his issue, as
i is calcula ed by di iding he SII by he popula ion mean o he heal h ou come.
Measu es based on he concen a ion cu e (CC) a e also used. These measu es
o igina ed in he economic analysis o income dis ibu ion, amously summa ized in
he Gini Coe icien – a measu e o how income o weal h o a popula ion is
dis ibu ed among i s elemen s. Equally, when a heal h ou come measu e is used, i is
possible o summa ize in one numbe how heal h is dis ibu ed, e lec ing no only he
expe ience o wo g oups, bu o he whole popula ion. Addi ionally, unlike he SII
and he RII, measu es based on he CC do no assume a linea ela ionship be ween
independen and dependen a iables.
An impo an dis inc ion ha can be done in he me hods used o calcula e HI is he
di e ence be ween ela i e and absolu e measu es. I has been a gued ha he use o
only absolu e o ela i e measu es can be misleading, as i can in luence he eade s’
pe cep ion o he magni ude, signi icance and e en di ec ion o HI (140, 141). In ac ,
me hodological e iews o he epo ing o HI ha e shown ha absolu e and ela i e
measu es o he same e ec can yield opposi e esul s (141). Addi ionally, he choice
o ela i e o absolu e measu es can also e lec di e en equi y alue judgmen s
(142). When compa ing wo g oups ha ge heal hie a an equip opo iona e a e –
i.e., in bo h g oups’ heal h imp o es a an X% a e – hen a ela i e measu e o HI
will emain he same, while an absolu e measu e will change. On he o he hand, i
he g oups’ heal h imp o es in a uni o m way – i.e., bo h g oups see an o e all
imp o emen o X pe cen age poin s – hen an absolu e measu e o HI will no
change, while a ela i e measu e will change (142) 1.
1 This is be e illus a ed in he hypo he ical example ou lined in appendix 1.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
28
1.2.4. Which Mechanisms?
a) Pa hway Be ween Indi idual Socioeconomic S a us and Heal h
The s udy o he pa hways ha link SES o heal h is compa a i ely less common han
o i s de e minan s, ou comes o measu es. In 2001, Dide ichsen, E ans and
Whi ehead ou lined a amewo k o unde s anding he social o igins o HI (28) ha
summa izes hese pa hways ( igu e 3). A ha ime, li e a u e on he SDH was jus
escala ing and s a ing o ouch he opic o con ex as an impo an de e minan o
heal h, shying away om he adi ional concep ualiza ion o isk ac o s as indi idual
a ibu es. Dide ichsen’s amewo k ecognizes he ole o con ex in he c ea ion o
HI, al hough i mos ly ocuses on indi idual pa hways.
P obably he mos no iceable use o Dide ichsen’s amewo k was i s applica ion by
he WHO’s CSDH as a basis o hei own amewo k ( igu e 2) (12, 13).
Dide ichsen’s amewo k has also been used as a basis o o he amewo ks (143); as
a map o unde s and o he social phenomena, such as in ima e pa ne iolence (144)
and social consequences o disease (145); as a ame o p esen e idence o li e a u e
e iews on a ic inju ies in you h (146), in cys ic ib osis in he UK (147) and in
wo k- ela ed heal h (148); as a basis o policy compa isons be ween coun ies (145,
149, 150); and as a map o empi ical analysis o he heal h o lone mo he s (151,
152) and smoking in adolescen s (153).
Dide ichsen’s amewo k has no aised much academic discussion, and o he au ho s
who used i as a basis o hei own wo k did no explici ly c i ique i s applicabili y.
Despi e his, i p o ides a simple, ye comple e summa y o how SES in luences
heal h and ice- e sa. The amewo k desc ibes ou mechanisms: (I) social
s a i ica ion, (II) di e en ial exposu e, (III) di e en ial suscep ibili y and (IV)
di e en ial consequences; and ou en y poin s o policies o a ge hose
mechanisms: (A) in luencing social s a i ica ion, (B) dec easing exposu es, (C)
dec easing ulne abili y, and (D) p e en ing unequal consequences. Wi h his
amewo k, he au ho s aim o p o ide a model o unde s and he p ocess o c ea ion
o HI, a sys ema iza ion o wha kind o policies migh wo k in hei mi iga ion, and a
base o empi ically es which HI p oducing mechanisms a e mo e impo an in a
socie y.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
29
This amewo k p o ides a simple, ye exhaus i e, desc ip ion o how SES and heal h
ou comes a e in e ela ed. I can be easily applicable o any SES measu e and heal h
ou come, as he a ie y o analyses i has been used o clea ly shows. I also clea ly
iden i ies he s eps in which di e en ial e ec s occu , which in u n lead o HI.
Figu e 3. A amewo k o elucida ing he pa hways om he social con ex o heal h ou comes and o
in oducing policy in e en ions. Sou ce: Dide ichsen F, E ans T, Whi ehead M. The social basis o
dispa i ies in heal h: Challenging inequi ies in heal h: om e hics o ac ion. New Yo k: Ox o d
Uni e si y P ess; 2001.
i. Fi s Mechanism: Social S a i ica ion
Social s a i ica ion is he way con ex de e mines indi idual social posi ion ( igu e
3). ‘Con ex ’ is unde s ood by Dide ichsen (28) as ‘ he spec um o ac o s in socie y
ha canno be di ec ly measu ed a he indi idual le el’ (p. 19). As was la e
desc ibed by he au ho (154), he social s a i ica ion mechanism ac ually
encompasses wo mechanisms: ‘one ha gene a es and dis ibu es weal h and powe
o di e en social posi ions in socie y and one ha s a i ies indi iduals in o he social
posi ions’ (p. 59). Thus, he pa e n o heal h ac oss social posi ions is a esul o bo h
he cha ac e is ics o he posi ions and o he indi iduals occupying hem.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
30
Unde he au ho ’s unde s anding, he p ocess o social s a i ica ion occu s mos ly
du ing ea ly childhood de elopmen (155); a his s age, a ange o de e minan s
ope a es o de e mine social posi ion and heal h in adul li e. Fo example, in a sample
o he Po uguese popula ion, heigh (as a p oxy measu e o childhood social
ci cums ances) was s ongly associa ed wi h se e al heal h ou comes, such as as hma
and ch onic pain, such ha alle people (who ended o ha e had be e childhood
ci cums ances) we e heal hie (156). The exis ence o li e-long de e minan s
highligh s he impo ance o a li e-cou se app oach o he analysis o HI.
Policies ha in luence social s a i ica ion usually all ou o he ealm o ‘heal h
policies’. These a e policies ha dec ease social inequali ies, such as c ea ing equal
educa ional oppo uni ies o edis ibu ing weal h. Because social posi ion is
inex icably linked o heal h, educ ions in social inequali ies ha e he po en ial o
also educe HI. As po e y has also been ex ensi ely linked o heal h, hese policies
can be pa icula ly impo an in p o ec ing he mos ulne able – h ough, o
example, illness pensions.
ii. Second Mechanism: Di e en ial Exposu e
Di e en ial exposu e e e s o he unequal dis ibu ion in ype, amoun o du a ion o
exposu es ha impac heal h on di e en social g oups. Unequal exposu es comp ise
en i onmen al, biological o beha iou al isk ac o s, which a e commonly connec ed
o social posi ion. Fo example, an unskilled wo ke may ha e a low income ha does
no allow hem o choose a heal hy die ; a pe son li ing in an u ban en i onmen is
exposed o mo e ai pollu ion; and he s ess o ha ing a low income can make a
pe son mo e p one o smoke. Whils social s a i ica ion ope a es mainly in ea ly li e,
di e en ial exposu es can occu in childhood o adul li e, as a consequence o he
social s a i ica ion p ocess.
Many heal h policies ha employ isk educ ion s a egies – o example, media
campaigns o p omo e heal hy ea ing by in o ming people o wha cons i u es a
heal hy die – do no di e en ia e be ween social g oups. Howe e , heal h campaigns
each indi iduals di e en ly, as he mo e educa ed can be mo e exposed.
Acco dingly, analyses o hese s a egies ha e shown ha , despi e imp o ing some
people’s heal h, hey some imes inc ease HI, as hey disp opo iona ely imp o e he
heal h o hose ha a e heal hie o s a o wi h (157).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
31
To educe exposu es, one mus ‘modi y he e ec o social posi ion on he occu ence
o he speci ic causes’ (154: p.60). This means s a egies should aim o educe he
disp opo iona e amoun o isk ac o s ha some people ace, ocusing on pa icula
g oups ha ace hem, o example, by p o ec ing hem om occupa ional isks, bad
housing, o inadequa e nu i ion. No iceably, di e en ial exposu es end o clus e , as
people in lowe social s a a a e mo e likely o be exposed o mul iple ad e se isk
ac o s. This clus e ing o ad e se exposu es h ough li e cons i u es he hi d
mechanism: di e en ial ulne abili y.
iii. Thi d Mechanism: Di e en ial Vulne abili y
The e ec o an exposu e on an indi idual is no exclusi ely a unc ion o he
exposu e, bu also o he indi idual him/he sel . Fo Dide ichsen e al. (155), he
added exposu es o mul iple isk ac o s inc ease he ulne abili y o people in lowe
social posi ions. These exposu es ac syne gis ically, making he indi idual mo e
suscep ible o he e ec o each o hem. This means ha e en i a gi en isk ac o is
dis ibu ed e enly ac oss social g oups, i s impac may be une enly dis ibu ed among
hose g oups due o di e en unde lying ulne abili y (28). Thus, he hi d mechanism
is ‘mos ly a ques ion o clus e ing o lowe socio-economic g oups o causes in he
same pa hway’ (154: p.60).
The success o policies ha aim o dec ease isky exposu es also depends on he
exis ence o o he exposu es and on he con ex in which he indi idual is in. Fo
example, a policy migh be pu in place o p o ide housing o e e yone, bu a
homeless indi idual wi h an incapaci a ing men al illness and no o he o m o
suppo will no be able o na iga e he adminis a i e p ocess o apply o he house
hey need. Reducing ulne abili y depends on jus ha : ackling in e ac ing exposu es
and no jus ocusing on a single one.
Howe e , ulne abili y is no only abou he addi i e o in e ac ing e ec o se e al
exposu es, i is also abou con ex ual e ec s. As he Dide ichsen poin s ou (158),
‘child en li ing in ex eme po e y ha e e y di e en mo ali y a es in di e en
coun ies, which shows ha he na ional policy con ex modi ies he e ec o po e y’
(p. 14). Fo example, a socie y wi h s ong social cohesion can po en ially educe he
e ec s o po e y o unemploymen in an indi idual’s heal h, by educing he s ess
associa ed wi h hese si ua ions.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
32
Thus, educing ulne abili y mus include comp ehensi e s a egies ha ackle
mul iple exposu es simul aneously, and p o iding people wi h an en i onmen ha
helps mi iga e he e ec s o indi idual isk ac o s.
i . Fou h Mechanism: Di e en ial Consequences
Heal h is a undamen al good, aluable no only o i s own sake, bu also o how i
allows indi iduals o ul il hei expec a ions abou hei li es. Illness can ha e social
and economic consequences, which can eed back in o he mechanism o social
s a i ica ion (mechanism I in igu e 3). Fo example, loss o a limb may lead o
ex ensi e heal hca e paymen s and also o los income due o inabili y o wo k; hese
di ec and indi ec cos s can ha e emendous consequences in a amily’s budge .
Howe e , his impac depends on o he de e minan s, such as how well o he amily
was be o e he heal h e en o he social suppo ha is a ailable – such as uni e sal
heal hca e o disabili y insu ance. Depending on hese, he consequences can be mo e
o less g a e, changing he likelihood o ‘ alling behind’.
The consequences o disease can also ha e an e ec on an agg ega e le el, as high
a es o illness can in luence a coun y’s social and economic de elopmen . An
example o his is he impac o HIV in Sou h A ica: in 2000, he Wo ld Bank
p ojec ed ha G oss Domes ic P oduc (GDP) would be 17% lowe in 2010 due o he
high a es o he disease (159).
Policies aimed a educing he social consequences o disease include hose ela ed o
he p o ision o heal hca e (including p ima y, seconda y and e ia y), and hose
aimed a mi iga ing he economic consequences o disease, such as p o iding wo k
oppo uni ies, bene i s o insu ance o people who a e ill. These policies, by p o iding
heal hca e and p omo ing ein eg a ion in he wo k o ce a e a pe son alls ill, ha e
he po en ial o b eak he cycle be ween SES and heal h.
b) Pa hways Be ween Con ex and Heal h and i s Dis ibu ion
Despi e ex ensi e e idence connec ing mul iple con ex ual cha ac e is ics wi h
indi idual and popula ion heal h, he pa hways be ween he wo ha e no been
pa icula ly explo ed (160). Macin y e e al. (14) called his he ‘black box o places’
(p. 131), an unknown in luence ha we can see bu canno explain.
The amewo k o he CSDH ies o ill his gap. Acco ding o his amewo k,
con ex c ea es social s a i ica ion and dis ibu es indi iduals h ough s a a, which
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
33
ha e an impac on hei heal h (13). In his iew, con ex is composed o go e nance,
policy (mac oeconomic, social and heal h), and cul u al and socie al no ms and alues
( igu e 2) (12). This amewo k ook some ideas om Dide ichsen’s amewo k,
whose desc ip ion o he pa hways be ween con ex and heal h was mo e de ailed. In
ac , Dide ichsen’s amewo k can be app oached om a pe spec i e o he indi idual
o o socie y (150). When iewed om he pe spec i e o socie y, Dide ichsen’s
amewo k iden i ies wo p ocesses h ough which socie y impac s heal h and HI:
social s a i ica ion and policy en y-poin s.
In Dide ichsen’s wo ds (28), ‘[ he p ocess o social s a i ica ion] bo h alloca es
powe and weal h o social posi ions and allows indi iduals in o di e en posi ions’
(p. 21). Dide ichsen a gues ha he p ocess o social s a i ica ion is ‘cen al’ o he
issue o HI, in so much as i helps us o dis inguish be ween ‘ ai ’ and ‘un ai ’
inequali ies (i.e., inequali ies e sus inequi ies). The au ho a gues ha , once one
unde s ands he p ocess o social s a i ica ion, one can judge i as o whe he i is
‘ ai ’ o ‘un ai ’. As such, i powe and weal h a e dis ibu ed ‘ ai ly’ among social
posi ions o a socie y and i indi iduals a e ‘ ai ly’ alloca ed o hose posi ions, HI
s emming om ha p ocess can also be deemed ‘ ai ’ (i.e., no inequi ies2). I
emains, none heless, ha classi ying some hing as ‘ ai ’ o ‘un ai ’ is a no ma i e
exe cise, and hus depends on iews o jus ice.
Con ex can also in luence heal h and heal h dis ibu ion o he ex en ha i c ea es
in o mal and o mal ules ha in luence heal h, such as policies. Fo example,
uni e sal access o heal h ca e can help equalize oppo uni ies, as i helps indi iduals
who ha e allen ill o eco e , e-en e he wo k o ce and a oid a all in social
posi ion. In o mal ules can also ha e a heal h impac , such as when expec a ions
abou a neighbou hood allow i o main ain high le els o iolence. Fu he mo e,
hese ules can impac di e en g oups di e en ly. This in luence o con ex is
acknowledged in Dide ichsen’s amewo k o a la ge ex en h ough he policy ‘en y
poin s’ he iden i ies (dec easing exposu es, dec easing ulne abili y and p e en ing
unequal consequences). By iden i ying hese en y-poin s, he au ho desc ibes how
2 The dis inc ion be ween heal h inequi ies and inequali ies is no uni e sally accep ed, bu i is
gene ally conside ed o be a ques ion o whe he a mo al judgemen is made o no : while inequali y
and equali y a e pu ely desc ip i e – simply desc ibe a di e ence be ween wo g oups – inequi y and
equi y encompass a mo al iew – no only he e is a di e ence, bu i is an unjus di e ence.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
34
policies, by shaping he ules wi hin a socie y, in luence i s heal h and heal h
dis ibu ion.
In summa y, acco ding o Dide ichsen’s amewo k, con ex in luences heal h and
heal h dis ibu ion h ough wo majo mechanisms: social s a i ica ion and policy
en y poin s. Social s a i ica ion ope a es h ough he c ea ion o hie a chies in a
socie y, whe eas policy en y poin s in luence he pa hways be ween social posi ion
and heal h. Howe e , as Whi ehead, Bu s öm and Dide ichsen (150) poin ou , policy
is only one componen o social con ex ha ‘may ha e an in luence on he pa hways
be ween social posi ion and heal h’ (p. 257). A comp ehensi e socie al pe spec i e
needs o ocus on how all con ex ual componen s – no jus policy – in luence heal h
and i s dis ibu ion.
I emains ha , despi e he gene al ag eemen ha con ex in luences heal h and HI,
lack o unde s anding o he mechanisms by which his happens unde mines he
e idence ha is p oduced (14, 160). This is u he ein o ced by he obse a ion ha
a ious public heal h policies seem o ha e ailed o educe HI, e en when his was
hei explici goal (25, 161). This shows a need o sys ema ize he mechanisms by
which con ex in luences heal h and HI, o be e unde s and and s udy hem and o
design policies ha a e app op ia e o hei ou lined goals.
1.2.5. Summa y
The choice o heal h ou come, SES indica o , o measu e o he analysis o HI, can
e lec di e en esea ch ques ions and di e en no ma i e iews, and can ul ima ely
lead o di e en conclusions. Despi e his, HI ha e been shown o a a ie y o heal h
ou comes – om mo ali y, o mo bidi y, and heal h beha iou s –, o SES indica o s –
bo h indi idual and con ex ual –, and using a a ie y o di e en measu es.
The mechanisms ha link indi idual SES o heal h ou comes can be desc ibed in ligh
o Dide ichsen’s amewo k, which desc ibes a pa hway ha s a s in social
s a i ica ion – he way ha con ex de e mines indi idual social posi ion. Social
posi ion hen goes on o de e mine exposu e o isk ac o s, ulne abili y o hose
ac o s, and he consequences o heal h back on social posi ion. Dide ichsen
summa ises how con ex in luences HI in wo mechanisms: social s a i ica ion and
policies. Howe e , a comp ehensi e pe spec i e on con ex mus include o he
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
41
Po uguese cons i u ion, in e es in heal h equi y has been limi ed. A WHO epo on
he Po uguese Na ional Heal h Plan a gued ha HI we e an ‘impo an policy gap’ in
his plan (202). In an in e es ing analysis o his seeming lack o in e es , Bago d’U a
a gues ha i is he absence o explici and e ec i e policies o ackle HI ha allows
hem o emain so p e alen (203).
1.3.3. Summa y
Despi e conside able imp o emen s in o e all heal h and in social suppo in
Eu opean coun ies, HI emain high, in some cases e en inc easing in he las yea s.
This has been called a ‘pa adox’, as HI emain an impo an public heal h challenge in
he con inen .
Po ugal is a pa icula ly in e es ing case s udy o HI, as i is one o he mos unequal
Eu opean coun ies, bo h in e ms o income and heal h dis ibu ion. Cu en e idence
sugges s he exis ence o signi ican p o-poo inequali y in mos heal h ou comes and
o mos socioeconomic de e minan s, wi h a ew no iceable excep ions, such as
alle gies and smoking. On op o his, Po ugal has gone h ough impo an changes in
he las decade, namely wi h he implemen a ion o aus e i y measu es ha seem o
ha e had an impac on he p o ision o social se ices, hus po en ially inc easing HI.
Despi e his, poli ical a en ion o he issue in Po ugal is s ill e y limi ed, which may
be exac ly why HI emain so high.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
42
1.4. Objec i es
The o e all aim o his disse a ion is o con ibu e o he unde s anding o how
cha ac e is ics o he con ex can ha e an impac on popula ion heal h and heal h
dis ibu ion, using Po ugal and Eu ope as case s udies.
To accomplish his aim, he ollowing objec i es we e pu sued:
• To analyse and in e p e how changes in indi idual and con ex ual social
capi al, and he in e ac ion be ween he wo, we e associa ed wi h changes in
SAH in Eu opean coun ies be ween 2002 and 2012.
• To analyse and in e p e how he ela ionship be ween social mobili y and HI
a ied be ween six wel a e egime ypes in Eu opean coun ies be ween 2002
and 2012.
• To collec , summa ise, desc ibe, and in e p e a ailable e idence abou
socioeconomic HI in Po ugal.
• To ou line how social inequali ies in heal h limi a ions changed in Po ugal
be ween 2004 and 2014, conside ing di e en measu es o social s a us, and
in e p e he esul s in he ligh o mac oeconomic changes in he coun y in
ha pe iod.
• D awing on he indings om he p e ious analyses, o ou line a heo e ical
amewo k ha summa ises how con ex in luences popula ion heal h and
heal h dis ibu ion.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
43
1.5. Me hodological App oaches
This esea ch used seconda y da a collec ed be ween 2002 and 2014 in Eu opean
coun ies. Acco ding o he ules and egula ions o he E hical Council o he
Ins i u e o Hygiene and T opical Medicine o he No a Uni e si y o Lisbon, his
esea ch did no equi e e hical app o al om he Council (204).
1.5.1. Da a Sou ces
This wo k was based on da a om wo main da abases: he Eu opean Social Su ey
(ESS) and he Eu opean Union Su ey on Income and Li ing Condi ions (EU-SILC).
a) Eu opean Social Su ey
The ESS is a epea ed c oss-sec ional su ey ha collec s da a on a i udes, belie s
and beha iou pa e ns (205). The su ey is applied e e y wo yea s in mo e han
hi y Eu opean coun ies since 2002. Coun ies a e ee o pa icipa e o no e e y
yea he su ey is pe o med. The su ey is join ly unded by he EU and each
pa icipa ing coun y (206). Da a is made eely a ailable online o esea che s, upon
a simple egis a ion p ocess on he websi e (207).
ESS aims o achie e a ep esen a i e sample on each coun y o pe sons o e 15 yea s
old li ing in p i a e households. Each coun y is gi en he eedom o choose hei
p e e ed sampling design, conside ing cos s, expe ience and o he coun y speci ic
ac o s. Howe e , a ew equi emen s a e applied o e e y coun y o ensu e
compa abili y o he samples, such as he use o s ic andom p obabili y me hods a
e e y s age, a high esponse a e (minimum 70%), a ull co e age o he popula ion,
and a minimum e ec i e sample size (n=1,500 o n=800 in coun ies whe e he
popula ion is smalle han 2 million) (208).
The ESS ques ionnai e consis s o a co e sec ion and a o a ing sec ion. The co e
module ul ils ESS’s p ima y ole, o moni o ing change in alues and a i udes in
Eu ope h ough ime. The o a ing modules a e selec ed based on a call o p oposals
made in he O icial Jou nal o he EU. In 2014, he o a ing modules we e on ‘Social
inequali ies in heal h and hei de e minan s’ and on ‘a i udes owa ds immig a ion
and hei an eceden s’ (209). The ESS co e ques ionnai e includes wo heal h ela ed
ques ions: SAH (‘How is you heal h in gene al?’) and hampe ed in daily ac i i ies
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
44
(‘A e you hampe ed in you daily ac i i ies in any way by any longs anding illness, o
disabili y, in i mi y o men al heal h p oblem? I yes, is ha a lo o o some ex en ?’).
ESS esul s ha e been widely used in academic esea ch and in policy documen s.
The ESS bibliog aphy includes hund eds o publica ions ha show he ange o use
his su ey has had (210), including no only analyses o su ey esul s, bu also b oad
discussions on su ey me hodology.
b) Eu opean Union Su ey on Income and Li ing Condi ions
EU-SILC is an annual su ey ca ied ou in se e al Eu opean coun ies wi h a mixed
longi udinal and c oss-sec ional design. The su ey is egula ed by EU law as a way
o compiling compa able da a on income, po e y and social exclusion wi hin he
union, using ha monized me hods and de ini ions (211). As such, e e y EU coun y is
expec ed o pa icipa e, by se ing up i s own da a collec ion o using exis ing su eys
ha comply wi h EU-SILC equi emen s. The EU unds he i s ou yea s o da a
collec ion o each membe s a e. Da a is made a ailable o scien i ic pu poses gi en
he esea che s’ compliance wi h a numbe o p i acy equi emen s. To access his
da a, au ho isa ion was sough om and p o ided by Eu os a ’s Mic oda a Access
Team.
The su ey’s longi udinal componen ollows a simple o a ional design: in yea one,
a c oss-sec ional sample is selec ed; his sample is di ided in ou sub-samples, each
i sel ep esen a i e o he popula ion. In yea wo, one sub-sample is d opped, he
o he h ee a e ollowed up, and one new sub-sample is added. As such, excep o he
h ee i s sub-samples, e e y sub-sample is eques ed o be pa o he su ey o ou
consecu i e yea s. In any one pa icula yea , he o e all sample made up o ou sub-
samples, which make up he c oss-sec ional sample (212).
EU-SILC aims o in e iew a ep esen a i e sample o people aged 16 o o e li ing
in a p i a e household. Sample size depends on coun y size; o example, minimum
e ec i e sample size o he c oss-sec ional sample in Po ugal is 10,500 and 7,500
o he longi udinal componen . This adds up o a minimum sample size o 166,000
pe yea in he c oss-sec ional sample, when all coun ies a e combined (211). Jus
like he ESS, sampling p ocedu es can be de ined wi hin each coun y, as long as hey
ollow ce ain equi emen s ha make he samples compa able, such as he use o
p obabili y sampling and o households as he basic uni o sampling (213).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
45
Mos o he EU-SILC ques ionnai e conce ns li ing condi ions, po e y, and income.
Th ee heal h ela ed ques ions a e included:
• SAH: ‘How is you heal h in gene al?’ allowing ollowing answe s:
o Ve y good / Good / Fai / Bad / Ve y bad / Don’ know / Re usal o
answe
• Ch onic condi ions: ‘Do you ha e any long-s anding illness o heal h
p oblem?’ allowing ollowing answe s:
o Yes / No / Don’ know / Re usal o answe
• Limi a ions by heal h condi ions: ‘Fo a leas he pas six mon hs, o wha
ex en ha e you been limi ed because o a heal h p oblem in ac i i ies people
usually do?’ allowing ollowing answe s:
o Se e ely limi ed / Limi ed bu no se e ely / No limi ed a all / Don’
know / Re usal o answe
Eu os a uses his las a iable – limi a ions by heal h condi ions – as a measu e o
disabili ies (212).
EU-SILC esul s a e a undamen al sou ce o da a o he wo k o he Eu opean
Commission. They ha e been ex ensi ely used in he p oduc ion o books, scien i ic
publica ions, poli ical s a emen s, and s a is ical wo king pape s, among o he s (214).
1.5.2. Me hods
a) Sys ema ic Re iew o he Li e a u e
A sys ema ic e iew (SR) can be de ined as a ‘ e iew o he scien i ic e idence which
applies s a egies ha limi bias in he assembly, c i ical app aisal, and syn hesis o all
ele an s udies on he speci ic opic’ (33: p.276). SR a e impo an gi en he
ou s anding numbe o scien i ic publica ions and he amoun o exis ing e idence,
some imes con adic o y, on a pa icula opic (215). Thus, he alue o SR has long
been es ablished, especially o clinical p ac ice, as hey p o ide quick and easy
access o a summa y o he a ailable e idence o busy clinicians (216).
Public heal h in e en ions a e usually mo e complex han he adi ional andomized
clinical ial. They can ac on di e en le els simul aneously – di ec ly wi h he
indi idual o on a b oade , con ex ual le el – and h ough mul iple mechanisms.
Some imes, andomized in e en ions a e no easible o p ac ical o e hical easons.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
46
This means ha he adi ional me hodological guidance o SR can be insu icien o
ace his complexi y (215), and public heal h esea che s ha e o be c ea i e when
doing a SR. This includes eso ing o al e na i e s udy designs, such as quali a i e o
obse a ional s udies (217). This p esen s i s own issues, as obse a ional s udies can
ind spu ious associa ions, and, in his si ua ion, he explo a ion o he e ogenei y
migh yield be e insigh s han a emp s o look o an o e all measu e o e ec
(218).
To help o e come limi a ions associa ed wi h SR, he PRISMA guidelines sys ema ise
o e a ching p inciples ha should be applied (PRISMA s ands o P e e ed
Repo ing I ems o Sys ema ic Re iews and Me a-Analyses). These guidelines (216)
consis o a 27-i em checklis and a low diag am ou lined by expe s and, as much as
possible, based on a ailable e idence, ha aim o ‘imp o e he epo ing o SR and
me a-analysis’ (p. 2). The p oposed diag am ( igu e 4) sugges s ha all s eps ha lead
o he inclusion o a ce ain numbe o s udies should be eco ded and explained in
de ail, including sou ces and easons o exclusion. The 27-i em checklis includes
guidance on all elemen s o he SR, om he i le, abs ac , in oduc ion, me hods,
esul s, discussion and unding.
Figu e 4. Flow o in o ma ion h ough he phases o a sys ema ic e iew p oposed by he PRISMA
s a emen . Sou ce: Mohe D e al. P e e ed epo ing i ems o sys ema ic e iews and me a-analyses:
he PRISMA s a emen . BMJ 2009;339(7716):332.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
47
b) S a is ical Me hods
i. Logis ic Reg ession
Reg ession analyses a e an impo an pa o esea ch in HI. Bina y logis ic eg ession
analyses a e a pa icula ype o eg ession analyses ha conce n hemsel es wi h
bina y ou comes, i.e., when he heal h a iable only akes wo dis inc alues.
Al hough he gene al p inciples o he logis ic eg ession a e simila o hose o he
linea eg ession, he e a e di e ences in he o m o he model and i s assump ions
(219). The goal o any eg ession analysis is o ind he bes i ing, mos
pa simonious, and in e p e able model o a ela ionship be ween a se o explana o y
a iables and an ou come a iable (219). Once i ed, he selec ed model yields an
es ima e o each coe icien o each o he independen a iables included. This
coe icien can be in e p e ed as a a e o change – o ‘a unc ion o he dependen
a iable pe uni o change in he independen a iable’ (220: p.49), holding all o he
independen a iables cons an . In p ac ice, he coe icien is he di e ence be ween
he log o he odds o wo di e en alues o he independen a iable.
In he analysis o HI, he independen a iables a e usually he SES a iables o
in e es , such as income o educa ion. Changes in he scales o he log-odds a e no
easy o in e p e ; howe e , logis ic eg ession coe icien s can be easily con e ed o
OR. These, on he o he hand, a e easily in e p e ed as he a io o he odds o he
ou come a iable be ween wo g oups de ined by he independen a iable (220). Fo
example, i he heal h ou come is mo ali y (y=1 o dea h, y=0 o su i al), and
educa ion is he independen a iable (x=0 o less han high educa ion, x=1 o high
educa ion), an OR=2 means ha he odds o dying among he less educa ed a e wo
imes highe han he odds o dying among he mo e educa ed. This is also applicable
o con inuous independen a iables, conside ing a 1-uni o an x-uni inc ease (220).
Using he same example, bu i ins ead o educa ion we use income, an OR=2 may
mean ha o e e y inc ease in uni o income (1 €, 1.000 £, 100 $, depending on he
scale used), he odd o dea h dec ease by hal .
ii. Mul ile el Models
Ecological a iables ha e been dismissed by epidemiology o a long ime,
pa icula ly since he iden i ica ion o he ecologic allacy, which s a es ha
indi idual ela ionships canno be in e ed om ecologic ela ionships (15).
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
48
Con e sely, in he o he ex eme, comple ely igno ing he e ec s o con ex ual
cha ac e is ics can lead o he indi idualis ic (o a omis ic) allacy – ‘an e oneous
in e ence abou causal ela ionships in g oups o people made on he basis o
ela ionships obse ed in indi iduals’ (33: p. 11). To answe his need, s a is ical
me hods mus include bo h indi idual and g oup le el cha ac e is ics, i.e., hey mus
be mul ile el. Mul ile el me hods a e eg ession-based models ha ake in o accoun
he hie a chical s uc u e o he da a, o example, a he indi idual and
neighbou hood le el.
The concep o heal h de e minan s as bo h indi idual and con ex ual na u ally leads
o a mul ile el pe spec i e. Se e al o he easons also wa an he use o mul ile el
analyses when s udying SDH. Fi s , mul ile el models allow o he simul aneous
es ima ion o eg ession coe icien s o a iables a mul iple le els. This is essen ial,
as he esul o a single le el analysis migh in ac be an a e ac , e lec ing a
ela ionship ha uly only exis s a a di e en le el (18). Second, hey can
disen angle complex ques ions o con ex ual and indi idual he e ogenei y. While
con ex s can ha e an o e all e ec on popula ion heal h, hey migh do so by a ec ing
only a pa icula g oup (con ex ual he e ogenei y); on he o he hand, he a iabili y o
a heal h ou come wi hin a con ex may be e y di e en among di e en g oups
(indi idual he e ogenei y). Thi d, mul ile el models allow o he analysis o
in e ac ions be ween a iables a di e en le els (indi idual-con ex ual in e ac ions).
These a e impo an as he same con ex may some imes ha e opposi e heal h e ec s
on di e en g oups (221). Fou h, hey can sequen ially include mul iple le els o
hie a chical clus e ing, om indi idual, o households, communi ies, and egions, o
example (222). They also allow o mo e complex da a s uc u es, such as c oss-
classi ied and mul iple membe ship, which allow indi iduals o be assigned o
mul iple g oups simul aneously (223). Finally, mul ile el models can also ake in o
accoun he ime dimension, such as when obse a ions a e nes ed wi hin ime
a iables (such as yea ), which a e hen nes ed wi hin egion, o example (18).
iii. Concen a ion Index
The CIx is a measu e o HI based on he CC. The CC is he esul o plo ing he
cumula i e pe cen age o indi iduals, anked by income, wi h he cumula i e
pe cen age o he heal h a iable. Figu e 5 shows a hypo he ical example o a CC. In
plo ing a CC, pe ec equali y is ep esen ed by a diagonal line, showing a pe ec ly
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
49
equal dis ibu ion o heal h among he sample popula ion, ega dless o income. The
CIx is calcula ed as wice he a ea be ween he CC and he line o pe ec equali y.
When he e is no inequali y, heal h is dis ibu ed equally wi hin he popula ion, he
CC coincides wi h he diagonal and he CIx is ze o. In he o he ex eme, i heal h is
concen a ed in one pe son, he CC is shaped like an in e ed ‘L’, and he CIx is 1 (o
-1).
Figu e 5. Hypo he ical concen a ion cu e. The x-axis ep esen s he cumula i e p opo ion o he
popula ion, anked om poo es o iches . The y-axis ep esen s he cumula i e p opo ion o he
heal h a iable. In his example, heal h is disp opo iona ely concen a ed among he iches , as, o
example, he poo es hal o he popula ion only ha e abou 25% o he heal h a iable. Sou ce:
au ho ’s own elabo a ion.
In he pa icula case o bina y heal h ou comes, he CIx is no limi ed by he (-1,1)
ange, bu depends on he mean o he ou come a iable in he popula ion. As his
limi s compa abili y be ween di e en popula ions (ac oss ime o be ween a eas, o
example), Wags a (2005) p oposed a ‘no malisa ion’ o he CIx, by which i is
di ided by 1 minus he mean, making i compa able (224).
Wags a , an Doo slae , and Wa anabe (2003) ha e shown ha he CIx can be
decomposed in o he con ibu ions o indi idual ac o s o he income- ela ed HI
(225). These ac o s a e usually demog aphic a iables, such as age and sex, o o he
SES, such as educa ion o occupa ion. The con ibu ion o each ac o depends on wo
cha ac e is ics: he elas ici y o ha ac o wi h espec o he heal h a iable, and he
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
50
deg ee o income- ela ed inequali y o ha ac o (i.e., he CIx o ha ac o ). The
con ibu ion o each ac o o he o e all CIx is he p oduc o he heal h elas ici y and
he CIx o ha ac o .
1.5.3. Summa y
The exis ence o a social g adien in heal h shows how heal h is no de e mined only
by indi idual SES, bu depends on he con ex he pe son is in. This concep ual
app oach canno be explo ed using only adi ional s a is ical me hods, bu needs
mo e ad anced s a is ical models o conside he complexi y and di e en dimensions.
Mul ile el analysis allows o he desc ip ion o bo h indi idual and con ex ual
cha ac e is ics and o he quan i ica ion o hei impac on heal h. While no
excluding o he s a is ical me hods, such as simple eg ession analyses and me hods
based on he CC, mul ile el models can be e e lec he hie a chical na u e o heal h
de e minan s.
The CIx, on he o he hand, allows o a di e en analysis o HI. While no including
con ex ual de e minan s, i e lec s he o e all expe ience o he popula ion.
This esea ch used wo eg ession-based me hods: single le el and mul ile el logis ic
eg essions. I was also used measu es based on he CC, namely he CIx and i s
decomposi ion. Fu he mo e, a SR o he li e a u e was pe o med, ollowing he
PRISMA guidelines.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
57
113. Johansson E. A no e on he impac o hou s wo ked on mo ali y in OECD
coun ies. The Eu opean Jou nal o Heal h Economics. 2004;5(4):335-40.
114. Ruhm CJ. A e ecessions good o you heal h? The Qua e ly jou nal o
economics .115.2 (2000): 617-650.
115. Ca alano R, Goldman-Mello S, Sax on K, Ma ge ison-Zilko C, Subba aman M,
LeWinn K, e al. The heal h e ec s o economic decline. Annual e iew o public
heal h. 2011;32.
116. Ka asek RA, Theo ell T. Heal hy wo k: s ess, p oduc i i y, and he
econs uc ion o wo king li e. Basic books; 1992.
117. B uckne TA. Economic an eceden s o p one in an sleep placemen among
black mo he s. Annals o epidemiology. 2008;18(9):678-81.
118. McC one A, Ushe E, Sonn ag-O’B ien V, Moslene U, G üning C. Global
ends in enewable ene gy in es men 2012. F ank u School UNEP Collabo a ing
Cen e o Clima e and Sus ainable Ene gy Finance. 2012.
119. Buonoco e J. Mi iga ion and heal h: Clima e policy no so cos ly. Na u e Clima e
Change. 2014;4(10):861-2.
120. Bacigalupe A, Escola -Pujola A. The impac o economic c ises on social
inequali ies in heal h: wha do we know so a ? In e na ional jou nal o equi y in
heal h. 2014;13(1):52.
121. Chen L, Be lingue G, E ans T, Whi ehead M, Dide ichsen F, Bhuiya A, e al.
Heal h equi y in a globalizing wo ld. In: E ans T, edi o . Challenging inequi ies in
heal h: om e hics o ac ion. New Yo k: Ox o d Uni e si y P ess; 2001. p. 34-44.
122. Wilkinson RG. Socioeconomic de e minan s o heal h. Heal h inequali ies:
ela i e o absolu e ma e ial s anda ds? BMJ. 1997;314(7080):591.
123. Zajaco a A, Dowd JB. Reliabili y o sel - a ed heal h in US adul s. Ame ican
jou nal o epidemiology. 2011;174(8):977-83.
124. Idle EL, Benyamini Y. Sel - a ed heal h and mo ali y: a e iew o wen y-se en
communi y s udies. Jou nal o heal h and social beha io . 1997:21-37.
125. Schni ke J, Bacak V. The inc easing p edic i e alidi y o sel - a ed heal h.
PloS one. 2014;9(1):e84933.
126. Singh-Manoux A, Guéguen A, Ma ikainen P, Fe ie J, Ma mo M, Shipley M.
Sel - a ed heal h and mo ali y: sho -and long- e m associa ions in he Whi ehall II
s udy. Psychosoma ic medicine. 2007;69(2):138-43.
127. F anks P, Gold MR, Fiscella K. Sociodemog aphics, sel - a ed heal h, and
mo ali y in he US. Social science & medicine. 2003;56(12):2505-14.
128. Bu s öm B, F edlund P. Sel a ed heal h: Is i as good a p edic o o
subsequen mo ali y among adul s in lowe as well as in highe social classes?
Jou nal o epidemiology and communi y heal h. 2001;55(11):836-40.
129. Bjo ne JB, Faye s P, Idle E. Sel - a ed heal h. Assessing quali y o li e.
2005:309-23.
130. Eu os a . Disabili y s a is ics in oduced 2015. A ailable om:
h p://ec.eu opa.eu/eu os a /s a is ics-
explained/index.php/Disabili y_s a is ics_in oduced. [Accessed June 1s 2017]
131. A endano M, A o AR, Mackenbach JP. Socio-economic dispa i ies in physical
heal h in 10 Eu opean coun ies. Mannheim Resea ch Ins i u e o he Economics o
Aging; 2005.
132. Rennie K, Jebb S. P e alence o obesi y in G ea B i ain. Obesi y e iews.
2005;6(1):11-2.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
58
133. B unne E, Ma mo M, Nanchahal K, Shipley M, S ans eld S, Juneja M, e al.
Social inequali y in co ona y isk: cen al obesi y and he me abolic synd ome.
E idence om he Whi ehall II s udy. Diabe ologia. 1997;40(11):1341-9.
134. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adai -Rohani H, e al. A
compa a i e isk assessmen o bu den o disease and inju y a ibu able o 67 isk
ac o s and isk ac o clus e s in 21 egions, 1990–2010: a sys ema ic analysis o he
Global Bu den o Disease S udy 2010. The Lance . 2013;380(9859):2224-60.
135. Okechukwu C, Da ison K, Emmons K. Changing heal h beha io s in a social
con ex . In: Be kman LF, Kawachi I, Glymou MM, edi o s. Social epidemiology.
Second edi ion. New Yo k: Ox o d Uni e si y P ess; 2014. p. 365-395.
136. Van Doo slae E, Masse ia C, Koolman X, G oup OHER. Inequali ies in access
o medical ca e by income in de eloped coun ies. Canadian medical associa ion
jou nal. 2006;174(2):177-83.
137. S i bu I. Inequali ies in heal h, does heal h ca e ma e ? Social inequali ies in
mo ali y in Eu ope, wi h a special ocus on he ole o he heal h ca e sys em.
Ro e dam: E asmus MC; 2008.
138. Wags a A, Paci P, Van Doo slae E. On he measu emen o inequali ies in
heal h. Social science & medicine. 1991;33(5):545-57.
139. Regido E. Measu es o heal h inequali ies: pa 1. Jou nal o epidemiology and
communi y heal h. 2004;58(10):858.
140. King NB, Ha pe S, Young ME. Use o ela i e and absolu e e ec measu es in
epo ing heal h inequali ies: s uc u ed e iew. BMJ. 2012;345:e5774.
141. Kelly MP, san é CdlOsldsdl, Bonne oy J. The social de e minan s o heal h:
de eloping an e idence base o poli ical ac ion. Na ional Ins i i u e o Clinical
Excellence; 2007.
142. Allanson P, Pe ie D. On The Choice O Heal h Inequali y Measu e Fo The
Longi udinal Analysis O Income‐Rela ed Heal h Inequali ies. Heal h economics.
2013;22(3):353-65.
143. Due P, K ølne R, Rasmussen M, Ande sen A, Damsgaa d MT, G aham H, e al.
Pa hways and mechanisms in adolescence con ibu e o adul heal h inequali ies.
Scandina ian Jou nal o Public Heal h. 2011;39(6 suppl):62-78.
144. La sen MM. Heal h Inequi ies Rela ed o In ima e Pa ne Violence Agains
Women. The Role o Social Policy in he Uni ed S a es, Ge many, and No way.
Swi ze land: 2016.
145. Whi ehead M, Han a y B, Bu s om B. 3.1 Unequal consequences o ill heal h:
esea ching he ole o public policy. In: G aham H, edi o . Unde s anding Heal h
Inequali ies. 2009. p.181-198.
146. La lamme L, Dide ichsen F. Social di e ences in a ic inju y isks in childhood
and you h—a li e a u e e iew and a esea ch agenda. Inju y P e en ion.
2000;6(4):293-8.
147. Taylo -Robinson D, Diggle P, Smy h R, Whi ehead M. Heal h T ajec o ies in
People wi h Cys ic Fib osis in he UK: Explo ing he E ec o Social Dep i a ion. In:
Bu on-Jeang os C, Culla i S, Sacke A, Blane D, edi o s. A Li e Cou se Pe spec i e
on Heal h T ajec o ies and T ansi ions. London: Sp inge ; 2015. p. 85-110.
148. Toi anen S. Wo k- ela ed inequali ies in heal h. Cen e o Heal h Equi y
S udies. 2007.
149. Phipps S. Heal h ou comes o child en in Can ada, England, No way and he
Uni ed S a es. Social indica o s esea ch. 2007;80(1):179-221.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
59
150. Whi ehead M, Bu s öm B, Dide ichsen F. Social policies and he pa hways o
inequali ies in heal h: a compa a i e analysis o lone mo he s in B i ain and Sweden.
Social science & medicine. 2000;50(2):255-70.
151. F i zell S, Wei o GR, F i zell J, Bu s öm B. F om mac o o mic o: he heal h
o Swedish lone mo he s du ing changing economic and social ci cums ances. Social
science & medicine. 2007;65(12):2474-88.
152. Bu s om B, Whi ehead M, Clay on S, F i zell S, Vannoni F, Cos a G. Heal h
inequali ies be ween lone and couple mo he s and policy unde di e en wel a e
egimes– he example o I aly, Sweden and B i ain. Social science & medicine.
2010;70(6):912-20.
153. Schnoh CW, K eine S, Rasmussen M, Due P, Dide ichsen F. School- ela ed
media o s in social inequali ies in smoking: a compa a i e c oss-sec ional s udy o
20,399 adolescen s. In e na ional jou nal o equi y in heal h. 2009;8(1):17.
154. Dide ichsen F. Policies o heal h equi y: an e hical and epidemiological
amewo k and a ge s o a new na ional heal h policy in Sweden. Heal h Ca e
P io i y Se ing. 2003:57-62.
155. Dide ichsen F, Ande sen I, Manuel C, Ande sen A-MN, Bach E, Baadsgaa d M,
e al. Heal h Inequali y-de e minan s and policies. Scandina ian jou nal o public
heal h. 2012;40(8 suppl):12-105.
156. Pe elman J. A e ch onic diseases ela ed o heigh ? Resul s om he Po uguese
Na ional Heal h In e iew Su ey. Economics & Human Biology. 2014;15:56-66.
157. F eimu h VS. The ch onically unin o med: Closing he knowledge gap in heal h.
In: Ray EB, Donohew L, edi o s. Communica ion and heal h: Sys ems and
applica ions. Hillsdale, New Je sey: Law ence E lbaum Associa es; 1990:171-86.
158. Dide ichsen F. Resou ce alloca ion o heal h equi y: issues and me hods. Wo ld
Bank. 2004.
159. A nd C, Lewis JD. The mac o implica ions o HIV/AIDS in Sou h A ica: a
p elimina y assessmen . Sou h A ican Jou nal o Economics. 2000;68(5):380-92.
160. Galea S. In eg a i e chap e : mac osocial de e minan s o popula ion heal h. In:
Galea S, edi o . Mac osocial De e minan s o Popula ion Heal h. New Yo k:
Sp inge ; 2007. p. 295-7.
161. Mackenbach JP. The pe sis ence o heal h inequali ies in mode n wel a e s a es:
he explana ion o a pa adox. Social science & medicine. 2012;75(4):761-9.
162. Wo ld Heal h O ganisa ion. Eu opean Heal h Fo All Da abase. A ailable om:
h p://da a.eu o.who.in /h adb/. [Accessed on June 1s 2017].
163. Gla ze M. Wel a e s a e g ow h and he cu en c isis in Po ugal: Social
spending and i s challenges. Ins i u e o Eu opean S udies. 2012.
164. Guillén A, Ál a ez S, Sil a PAE. Redesigning he Spanish and Po uguese
wel a e s a es: he impac o accession in o he Eu opean Union. Sou h Eu opean
Socie y and Poli ics. 2003;8(1-2):231-68.
165. Van Ke m P, Alpe in MNP. Inequali y, g ow h and mobili y: The in e empo al
dis ibu ion o income in Eu opean coun ies 2003–2007. Economic Modelling.
2013;35:931-9.
166. Hespanha P, Po ugal S. Wel a e Cu s and Insecu i y unde he Rule o
Aus e i y: he Impac o he C isis on Po uguese Social Se ices. Oña i Socio-Legal
Se ies. 2015;5(4).
167. OECD. Social and Wel a e Issues: Inequali y 2014. A ailable om:
h p://www.oecd.o g/social/inequali y.h m. [Accesses June 1s 2017]
168. Ca ilho MJ. O declínio ecen e da mo alidade in an il em Po ugal. Re is a do
Cen o de Es udos Demog á icos. 1985;27:155-9.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
60
169. Lucas JS. Iniquidade social pe an e a doença e a mo e em Po ugal — 1985.
Re is a do Cen o de Es udos Demog á icos. 1986;n.º 28:29.
170. Pe ei a JACG. Equi y, heal h and heal hca e: an economic s udy wi h e e ence
o Po ugal. PhD disse a ion. Uni e si y o Yo k; 1995.
171. Go sens M, Ma í-Dell'Olmo M, Pé ez K, Palència L, Ma inez-Benei o M-A,
Rod íguez-Sanz M, e al. Socioeconomic inequali ies in inju y mo ali y in small
a eas o 15 Eu opean ci ies. Heal h & place. 2013;24:165-72.
172. Simões A, Paque e A, A aújo M. Equidade Ho izon al no sis ema de saúde
po uguês: sec o público s sec o p i ado. Associação Po uguesa de Economia da
Saúde. 2006.
173. Simões N, C espo N, Mo ei a SB, Va um CA. Measu emen and de e minan s o
heal h po e y and ichness: e idence om Po ugal. Empi ical Economics.
2016;50(4):1331–1358.
174. Ribei o S. Desigualdades Socioeconómicas na Doença Ca dio ascula em
Po ugal: Es udo baseado no Inqué i o Nacional de Saúde 2005/06. Mas e s Thesis.
No a Uni e si y o Lisbon; 2010.
175. Ribei o O, Teixei a L, A aújo L, A onso RM, Pachana N. P edic o s o anxie y
in cen ena ians: heal h, economic ac o s, and loneliness. In e na ional
Psychoge ia ics. 2014:1-10.
176. F aga S, Ma ques-Vidal P, Vollenweide P, Waebe G, Guessous I, Paccaud F, e
al. Associa ion o socioeconomic s a us wi h in lamma o y ma ke s: A wo coho
compa ison. P e en i e medicine. 2014.
177. Lawlo DA, Ha o M, Wedde kopp N, Ande sen LB, Sa dinha LB, Riddoch CJ,
e al. Associa ion o socioeconomic posi ion wi h insulin esis ance among child en
om Denma k, Es onia, and Po ugal: c oss sec ional s udy. BMJ.
2005;331(7510):183.
178. Sil a M. Heal h se ice usage in he Ribei a de Pena concelho o Po ugal. PhD
Disse a ion. Uni e si y o Exe e ; 1988.
179. Al es J, Kuns AE, Pe elman J. E olu ion o socioeconomic inequali ies in
smoking: esul s om he Po uguese na ional heal h in e iew su eys. BMC public
heal h. 2015;15(1):1.
180. Lopez AD, Collishaw NE, Piha T. A desc ip i e model o he ciga e e epidemic
in de eloped coun ies. Tobacco con ol. 1994;3(3):242.
181. Mo ei a PA, Pad ão PD. Educa ional and economic de e minan s o ood in ake
in Po uguese adul s: a c oss-sec ional su ey. BMC Public Heal h. 2004;4(1):58.
182. San os A-C, Ba os H. P e alence and de e minan s o obesi y in an u ban
sample o Po uguese adul s. Public Heal h. 2003;117(6):430-7.
183. San os AC, Eb ahim S, Ba os H. Gende , socio-economic s a us and me abolic
synd ome in middle-aged and old adul s. BMC Public Heal h. 2008;8(1):1.
184. Noguei a H, San ana P, San os R. Saúde: Vulne abilidade e Opo unidade na
Á ea Me opoli ana de Lisboa. In: San ana P, edi o . A Cidade e a Saúde. Coimb a:
Edições Almedina. 2007.
185. Nunes B, Sil a RD, C uz VT, Ro iz JM, Pais J, Sil a MC. P e alence and
pa e n o cogni i e impai men in u al and u ban popula ions om No he n
Po ugal. BMC neu ology. 2010;10(1):1.
186. Al es L, Aze edo A, Sil a S, Ba os H. Socioeconomic inequali ies in he
p e alence o nine es ablished ca dio ascula isk ac o s in a sou he n Eu opean
popula ion. PLoS One. 2012;7(5):e37158.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
61
187. Pe ei a M, Lune N, Paulo C, Se e o M, Aze edo A, Ba os H. Incidence o
hype ension in a p ospec i e coho s udy o adul s om Po o, Po ugal. BMC
ca dio ascula diso de s. 2012;12(1):1.
188. Al es E, Hen iques A, Co eia S, San os AC, Aze edo A, Ba os H.
Ca dio ascula isk p o ile o mo he s o a Po uguese bi h coho : A su ey 4yea s
a e deli e y. P e en i e medicine. 2013;57(5):494-9.
189. Sandes AR, Nascimen o C, Figuei a J, Gou eia R, Valen e S, Ma ins S, e al.
Alei amen o Ma e no: p e alência e ac o es condicionan es. Ac a Médica
Po uguesa. 2007;20:193-200.
190. Camões M, Lopes C, Oli ei a A, San os AC, Ba os H. O e all and cen al
obesi y incidence in an u ban Po uguese popula ion. P e en i e medicine.
2010;50(1):50-5.
191. San os MR, Vale MS, Mi anda L, Mo a J. Socio-demog aphic and pe cei ed
en i onmen al co ela es o walking in Po uguese adul s—A mul ile el analysis.
Heal h & place. 2009;15(4):1094-9.
192. Mo ei a P, San os S, Pad ão P, Co dei o T, Bessa M, Valen e H, e al. Food
pa e ns acco ding o sociodemog aphics, physical ac i i y, sleeping and obesi y in
Po uguese child en. In e na ional jou nal o en i onmen al esea ch and public
heal h. 2010;7(3):1121-38.
193. Ca elaa s AE, Kuns AE, Geu s JJ, C ialesi R, G ö ed L, Helme U, e al.
Educa ional di e ences in smoking: in e na ional compa ison. BMJ.
2000;320(7242):1102-7.
194. Veiga PA. Income- ela ed heal h inequali y in Po ugal. Uni e si y o Minho.
2005.
195. Ribei o S, Fu ado C, Pe ei a J. Associa ion be ween ca dio ascula disease and
socioeconomic le el in Po ugal. Re is a Po uguesa de Ca diologia (English
Edi ion). 2013;32(11):847-54.
196. Vilela S, Oli ei a A, Pin o E, Mo ei a P, Ba os H, Lopes C. The in luence o
socioeconomic ac o s and amily con ex on ene gy-dense ood consump ion among
2-yea -old child en. Eu opean jou nal o clinical nu i ion. 2015;69(1):47-54.
197. Kuns AE, Bos V, Ande sen O, Ca dano M, Cos a G, Ha ding S, e al.
Moni o ing o ends in socioeconomic inequali ies in mo ali y: expe iences om a
Eu opean p ojec . Demog aphic esea ch. 2004;2:229-54.
198. Oli ei a A, Maia B, Lopes C. De e minan s o inadequa e ui and ege able
consump ion amongs Po uguese adul s. Jou nal o Human Nu i ion and Die e ics.
2014;27(s2):194-203.
199. Sco KM, Al-Hamzawi AO, And ade LH, Bo ges G, Caldas-de-Almeida JM,
Fies as F, e al. Associa ions be ween subjec i e social s a us and DSM-IV men al
diso de s: esul s om he wo ld men al heal h su eys. JAMA psychia y.
2014;71(12):1400-8.
200. Eu opean Commission. Resea ch Findings – Social Si ua ion Moni o - Income
inequali y in EU coun ies. A ailable om:
h p://ec.eu opa.eu/social/main.jsp?ca Id=1050&in PageId=1870&langId=en.
Accessed on June 1s 2017.
201. Pe ei a J, Fu ado C. Equidade em saúde: do conhecimen o à acção. In:
DGS/ENSP, edi o . A No a Saúde Pública: A saúde Pública na E a do
Conhecimen o. Lisbon: G adi a; 2011.
202. Wo ld Heal h O ganisa ion. WHO e alua ion o he na ional heal h plan o
Po ugal (2004-2010). Copenhagen: WHO Regional O ice o Eu ope. 2010.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
62
203. Bago d'U a T. Equidade no sec o da saúde em Po ugal. In: Simões J, edi o . 30
Anos do Se iço Nacional de Saúde - um pe cu so comen ado. Lisbon: Simões, Jo ge;
2010.
204. Conselho de É ica do Ins i u o de Higiene e Medicina T opical da Uni e sidade
No a de Lisboa. Pedido de ap eciação é ica pa a p oje os e p o ocolos de
in es igação. Lisbon: CEIHMT-UNL; 2017.
205. ESS eam. Abou he Eu opean Social Su ey Eu opean Resea ch In as uc u e
– ESS ERIC. A ailable om: h p://www.eu opeansocialsu ey.o g/abou /. [Accessed
June 1s 2017]
206. ESS eam. Abou ESS - Funding. A ailable om:
h p://www.eu opeansocialsu ey.o g/abou / unding.h ml. [Accessed June 1s 2017]
207. Eu opean Social Su ey. F equen ly Asked Ques ions. A ailable om:
h p://www.eu opeansocialsu ey.o g/abou / aq.h ml. [Accessed June 1s 2017]
208. The ESS Sampling Expe Panel. Sampling o he Eu opean Social Su ey
Round VII: P inciples and Requi emen s. London: Cen e o Compa a i e Social
Su eys, Ci y Uni e si y London; 2014.
209. ESS eam. Ro a ing Modules. A ailable om:
h p://www.eu opeansocialsu ey.o g/me hodology/ques ionnai e/ o a ing_ques ionna
i e.h ml. [Accessed June 1s 2017]
210. ESS eam. ESS Bibliog aphy. A ailable om:
h p://www.eu opeansocialsu ey.o g/bibliog aphy/. [Accessed June 1s 2017]
211. Eu opean Commission. Regula ion (EC) No 1177/2003 o he Eu opean
Pa liamen and o he Council o 16 o June 2003 conce ning Communi y s a is ics on
income and li ing condi ions (EU-SILC). B ussels; 2003.
212. Eu os a . Heal h a iables in SILC – me hodology. A ailable om:
h p://ec.eu opa.eu/eu os a /s a is ics-
explained/index.php/Heal h_ a iables_in_SILC_-_me hodology-
Main_concep s_and_de ini ions. [Accessed June 1s 2017]
213. Eu opean Commission. Commission Regula ion (EC) No 1982/2003 o 21
Oc obe 2003 implemen ing Regula ion (EC) No 1177/2003 o he Eu opean
Pa liamen and o he Council conce ning Communi y s a is ics on income and li ing
condi ions (EU-SILC) as ega ds he sampling and acing ules, 1982/2003.
B ussels; 2003.
214. Eu os a . S a is ics on Income and Li ing Condi ions – Publica ions. A ailable
om: h p://ec.eu opa.eu/eu os a /web/income-and-li ing-condi ions/publica ions.
[Accessed June 1s 2017]
215. Khan KS, Te Rie G, Glan ille J, Sowden AJ, Kleijnen J. Sys ema ic e iews:
CRD's guidance o unde aking e iews in heal h ca e. 3 d edi ion. London:NHS
Cen e o Re iews and Dissemina ion; 2009.
216. Mohe D, Libe a i A, Te zla J, Al man DG. P e e ed epo ing i ems o
sys ema ic e iews and me a-analyses: he PRISMA s a emen . PLoS med.
2009;6(7):1-6.
217. Pe ic ew M. Sys ema ic e iews in public heal h: old ches nu s and new
challenges. Bulle in o he Wo ld Heal h O ganiza ion. 2009;87(3):163-A.
218. Egge M, Smi h GD, Schneide M. Sys ema ic e iews o obse a ional s udies.
In: Egge M, Smi h GD, Al man DG, edi o s. Sys ema ic Re iews in Heal h Ca e:
Me a-Analysis in Con ex , Second Edi ion. 2001:211-27.
219. Hosme DW, Lemeshow S. In oduc ion o he logis ic eg ession model. In:
Hosme DW, Lemeshow S, S u di an RX ,edi o s. Applied Logis ic Reg ession,
Thi d Edi ion. 2013:1-33.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
63
220. Hosme DW, Lemeshow S, S u di an RX. In e p e a ion o he Fi ed
Logis ic Reg ession Model. In: Hosme DW, Lemeshow S, S u di an RX, edi o s.
Applied Logis ic Reg ession, Thi d Edi ion. 2013:49-88.
221. Sub amanian S, Kim DJ, Kawachi I. Social us and sel - a ed heal h in US
communi ies: a mul ile el analysis. Jou nal o U ban Heal h. 2002;79(1):S21-S34.
222. Sub amanian S, Delgado I, Jadue L, Vega J, Kawachi I. Income inequali y and
heal h: mul ile el analysis o Chilean communi ies. Jou nal o epidemiology and
communi y heal h. 2003;57(11):844-8.
223. Fielding A, Golds ein H. C oss-classi ied and mul iple membe ship s uc u es in
mul ile el models: An in oduc ion and e iew. Uni e si y o B is ol. Resea ch
Repo RR791, 2006.
224. Wags a A. The bounds o he concen a ion index when he a iable o in e es
is bina y, wi h an applica ion o immuniza ion inequali y. Heal h economics.
2005;14(4):429-32.
225. Wags a A, Van Doo slae E, Wa anabe N. On decomposing he causes o
heal h sec o inequali ies wi h an applica ion o malnu i ion inequali ies in Vie nam.
Jou nal o econome ics. 2003;112(1):207-23.
The ela ionship be ween con ex and heal h inequali ies Chap e 1. In oduc ion
64
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
65
2. Resul s
2.1. The ‘da k side’ o social capi al: us and sel - a ed heal h in
Eu opean coun ies
Re e ence:
Campos-Ma os I, Sub amanian SV, Kawachi I. The ‘da k side’ o social capi al: us
and sel - a ed heal h in Eu opean coun ies. Eu opean Jou nal o Public Heal h.
2016;26(1):90-95. DOI: h p://dx.doi.o g/10.1093/eu pub/ck 089
Online supplemen a y da a o his publica ion is in Appendix 2.
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
66
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
73
2.2. Social mobili y and heal h in Eu opean coun ies: does wel a e
egime ype ma e ?
Re e ence:
Campos-Ma os I, Kawachi I. Social mobili y and heal h in Eu opean coun ies: does
wel a e egime ype ma e ? Social Science and Medicine. 2015;142:241-248 DOI:
h ps://doi.o g/10.1016/j.socscimed.2015.08.035
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
74
Sho communica ion
Social mobili y and heal h in Eu opean coun ies: Does wel a e egime
ype ma e ?
In^
es Campos-Ma os
a
,
b
,
*
, Ichi o Kawachi
b
a
Depa men o In e na ional Public Heal h and Bios a is ics, No a Uni e si y o Lisbon, Lisbon, Po ugal
b
Depa men o Social and Beha io al Sciences, Ha a d School o Public Heal h, Bos on, MA, USA
a icle in o
A icle his o y:
Recei ed 7 Oc obe 2014
Recei ed in e ised o m
10 Augus 2015
Accep ed 19 Augus 2015
A ailable online 22 Augus 2015
Keywo ds:
Eu ope
Wel a e egimes
Social mobili y
Sel - a ed heal h
abs ac
Heal h inequali ies pose an impo an public heal h challenge in Eu opean coun ies, o which inc eased
social mobili y has been sugges ed as a cause. We sough o desc ibe how he ela ionship be ween
heal h inequali ies and social mobili y a ies among wel a e egime ypes in he Eu opean egion. Da a
om six ounds o he Eu opean Social Su ey was analyzed using mul ile el s a is ical echniques,
s a ified by wel a e egime ype, including 237,535 indi iduals om 136 coun ies. Social mobili y
among indi iduals was defined acco ding o he disc epancy be ween pa en al and o sp ing educa ional
a ainmen . Fo each wel a e egime ype, he associa ion be ween social mobili y and sel - a ed heal h
was examined using odds a ios and isk di e ences, con olling o pa en al educa ion. Upwa dly mobile
indi iduals had be ween 23 and 44% lowe odds o epo ing bad o e y bad sel - a ed heal h when
compa ed o hose who emained s able. On an absolu e scale, o me USSR coun ies showed he bigges
and only significan di e ences o upwa d mo emen , while Scandina ian coun ies showed he
smalles . Downwa d social mobili y ended o be associa ed wi h wo se heal h, bu he esul s we e less
consis en . Upwa d social mobili y is associa ed wi h wo se heal h in all Eu opean wel a e egime ypes.
Howe e , in Scandina ian coun ies he associa ion o upwa d mobili y was smalle , sugges ing ha he
No dic model is mo e e ec i e in mi iga ing he impac o social mobili y on heal h and/o o heal h on
mobili y.
©2015 Else ie L d. All igh s ese ed.
1. In oduc ion
Despi e sus ained e o s pu in e ec ac oss Eu opean coun-
ies, heal h inequali ies pe sis as an impo an public heal h
challenge (Mackenbach, 2012). A ange o policy solu ions has been
ied, bu so a wi h ela i ely li le impac . Social mobili y has
been iden ified as an impo an d i e o heal h inequali ies. Social
mobili y can occu ei he be ween gene a ions (pa en s and chil-
d en) as well as wi hin he li e-cou se o he indi idual. T unca ed
in e gene a ional social mobili y is o pa icula conce n because i
can esul in he c ys alliza ion o weal h inequali y as well as
heal h inequali ies. Ill heal h is a po en cause o bo h in a-
indi idual and in e -gene a ional mobili y es ic ion. Fo
example, childhood illness has been shown o ad e sely a ec
educa ional a ainmen (Case and Paxson, 2008), which will
subsequen ly a ec an indi idual's success in he labo ma ke . Ill
heal h in midli e can a ec labo o ce pa icipa ion ( educed
wo king hou s, job loss), esul ing in downwa d income mobili y.
Res ic ed social mobili y can be mani es in mul iple dimensions e
educa ional achie emen , occupa ional s a us o ea nings and in-
come. Fu he mo e heal h selec ion can be bo h di ec (e.g.
dep essi e illness di ec ly esul ing in unca ed educa ional
achie emen ) as well as indi ec ee.g. dep essi e illness esul ing
in educed social mobili y ia in e media y ac o s such as s igma
and disc imina ion (Wes , 1991). Acco dingly, social p o ec ions
such as uni e sal access o heal h ca e o an i-disc imina ion
legisla ion ep esen impo an policies o p omo e bo h in a-
indi idual and in e -gene a ional social mobili y.
An indi idual's socioeconomic posi ion is a obus de e minan
o his/he heal h, bo h in e ms o hei cu en (o achie ed) so-
cioeconomic posi ion, bu also hei li e ime ajec o y (Ma mo
and Macmillan, 2004; Ma mo and Wilkinson, 2005). This can
eflec p ocesses o accumula ion o a di ec impac o social
mobili y (Hallq is e al., 2004). S udies on he e ec o social
mobili y on heal h ha e no always p oduced clea -cu esul s, wi h
*Co esponding au ho . Depa men o In e na ional Public Heal h and Bios a-
is ics, No a Uni e si y o Lisbon, Lisbon, Po ugal.
E-mail add ess: [email p o ec ed] (I. Campos-Ma os).
Con en s lis s a ailable a ScienceDi ec
Social Science & Medicine
jou nal homepage: www.else ie .com/loca e/socscimed
h p://dx.doi.o g/10.1016/j.socscimed.2015.08.035
0277-9536/©2015 Else ie L d. All igh s ese ed.
Social Science & Medicine 142 (2015) 241e248
some seeming o indica e ha upwa d social mobili y can be jus as
dele e ious o heal h as downwa d social mobili y (Hemmingsson
e al., 1999; Libe a os e al., 1988). These mixed esul s migh ,
howe e , be a consequence o he inconsis en ways in which social
mobili y has been ope a ionalized in he empi ical li e a u e
(Singhamme and Mi elma k, 2010). The use o di e en indica o s
o cha ac e ize social g oups can also be o consequence, since
di e en indica o s, such as educa ion, occupa ion o income, as
well as he in e gene a ional mo emen be ween hem, can ha e
di e en meanings (Galoba des e al., 2006).
O e all, he e a e bo h heo e ical and empi ical g ounds o
sugges ha he causal ela ionship be ween heal h and social
mobili y is bidi ec ional: indi iduals ha e mo e o less oppo u-
ni ies o social mobili y depending on hei heal h endowmen
and hei heal h achie emen is a ec ed by ansi ions be ween
social s a a.
The ex en o social mobili y a ies subs an ially be ween
coun ies (Belle and Hou , 2006). Go e nmen ac ions, such as
expanding access o schooling o in es ing in he heal h o child en
(e.g. ia imp o ed nu i ion o accina ion p og ams) ha e he
po en ial capaci y o b eak he in e -gene a ional ansmission o
social disad an age. Conside ing he s ong ela ionship be ween
social mobili y and heal h, hese go e nmen al ac ions, sys ema-
ized in Fig. 1, can ha e an impo an impac on heal h inequali ies.
Wel a e egime ypes, o en used o ca ego ize Eu opean coun ies,
sha e common policies such as he ones ou lined in Fig. 1.
In his c oss na ional compa a i e s udy, we sough o examine
he ela ion be ween social mobili y and popula ion heal h among
di e en ypes o wel a e egimes in he Eu opean egion, in o de
o unde s and how he wel a e s a e migh mode a e he link be-
ween mobili y and heal h.
2. Me hods
2.1. Da a sou ces and a iables
Indi idual da a was collec ed om six ounds o he Eu opean
Social Su ey (ESS), be ween 2002 and 2012, om hi y selec ed
coun ies. The ESS is a epea ed c oss-sec ional su ey ha collec s
compa able da a on indi idual socioeconomic cha ac e is ics and
heal h s a us o se e al Eu opean coun ies (ESS ERIC, 2014). Da a is
a ailable online a www.eu opeansocialsu ey.o g.
The ou come a iable, sel - a ed heal h, was based on he su -
ey pa icipan 's esponse o he ques ion ‘How is you heal h in
gene al?’, dicho omized so ha 1 included ‘bad’o ‘ e y bad’(o he
possible answe s we e ‘ ai ’,‘good’o ‘ e y good’).
Social mobili y was measu ed in ela ion o mo he and a he 's
achie ed le el o educa ion acco ding o he In e na ional S anda d
Classifica ion o Educa ion (ISCED) le els. Al hough social mobili y
is usually measu ed on he basis o he a he s' social s anding, he
inc easing pa icipa ion o women in he wo k o ce and he
impo ance o he mo he s' cha ac e is ics on child en's heal h
beha io s (Fa a o and San onas aso, 1995) suppo he impo ance
o conside ing mo he s' s a us in social mobili y s udies; he e o e,
his analysis was done sepa a ely. Social mobili y was classified in
h ee possible ca ego ies: ‘down’,‘s able’and ‘up’, acco ding o
whe he he esponden had eached, espec i ely, a lowe , he
same, o highe educa ional le el han his o he pa en . Ou
measu e o mobili y con olled o he pa en 's educa ional
achie emen when he esponden was 14 ( he same a iable used
o assess mobili y). Failing o ake in o accoun he ‘social g oup o
o igin’has been a common pi all in p e ious s udies o in e -
gene a ional social mobili y and heal h (Singhamme and
Mi elma k, 2010). Con olling o pa en 's educa ional achie e-
men yields mobili y coe ficien s ha can be in e p e ed as inde-
penden om social g oup o o igin.
O he indi idual-le el a iables included age ( es ic ed o 25
yea s and up), gende , ma i al s a us, belonging o an e hnic mi-
no i y g oup, sel -pe cei ed income, domicile and main occupa-
ional ac i i y. Responden s who we e in ull- ime educa ion we e
excluded, since no ha ing comple ed educa ion did no pe mi
compa ison o pa en s' achie emen . Fo all hese a iables a base
ca ego y wi h con as ing indica o a iables was specified, excep
age, which was cen e ed a ound i 's g and mean.
Fig. 1. En y poin s o educing and elimina ing heal h dispa i ies.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248242
To educe he possibili y o con ounding by economic de elop-
men , G oss Domes ic P oduc (GDP) pe capi a, con e ed o in-
e na ional dolla s using pu chasing powe pa i y, was e ie ed
om he Wo ld Bank da abase (Wo ld Bank, 2014) and included as
a coun y-le el a iable (specified pe coun y, pe yea ).
Addi ionally, he Gini coe ficien , which migh also con ound he
associa ion be ween social mobili y and heal h, was e ie ed om
he Eu os a da abase (Eu os a , 2014) and used as a le el 2 a iable
(coun y-yea specific). Howe e , his was only used as a sensi i i y
analysis, since he Gini coe ficien was missing o many coun ies
o se e al yea s.
2.2. Wel a e egimes
Coun ies we e g ouped by wel a e egime ype and analyzed
sepa a ely. Wel a e egime classifica ion is a much-deba ed opic,
no only wi h dispu ed ypologies, bu also ega ding which cha -
ac e is ics should be used o o hei classifica ion (Bamb a, 2007).
None heless, we s a ed wi h a widely used ypology ha di ides
Eu opean coun ies in o ou egime ypes:
(i) Scandina ian, cha ac e ized by uni e sal and gene ous
benefi s and a s ong edis ibu i e social secu i y sys em
(Eikemo e al., 2008a; Fenge , 2007);
(ii) Anglo-Saxon, wi h a low le el o go e nmen spending on
social p o ec ion, modes benefi s, usually means- es ed
(Eikemo e al., 2008a; Fenge , 2007);
(iii) Bisma ckian, wi h benefi s ied o employmen , financed
mainly by employe and employee, and minimal edis ibu-
ion (Eikemo e al., 2008a);
(i ) Sou he n, wi h a dualis sys em o wel a e p o ision, which
s ongly p o ec s pa o he popula ion while unde -
p o ec ing ano he (19).
This classifica ion is p ima ily based on Esping-Ande sen's e al.
(1990) g oundb eaking wo k, which ope a ionalized h ee p inci-
ples: decommodifica ion, social s a ifica ion and he public-
p i a e mix, o classi y he fi s h ee ypologies (Eikemo e al.,
2008a; Espig Ande sen e al., 1990). Fe e a (1996) la e added
he Sou he n ype, basing his classifica ion on he co e age o social
p o ec ion schemes (Fe e a, 1996). This ypology has been epli-
ca ed in o he a emp s o define wel a e egime ypes (Bamb a,
2007; Bonoli, 1997) and has been used p e iously in he heal h
li e a u e (Eikemo e al., 2008a, 2008b).
The conside a ion o Cen al and Eas e n Eu opean coun ies o
he Eu opean Union adds u he complexi y o his classifica ion.
His o ically, he ajec o ies o hese coun ies' wel a e ans-
o ma ion can be sepa a ed in wo, depending on he ex en o
which he wel a e e o collapsed in he 1990's (Cook and P ess,
2010). This ypology sepa a es Cen al and Eas e n Eu opean
coun ies (including Poland, Hunga y, Czech Republic and he Bal ic
s a es, among o he s) om he emaining o me USSR s a es (such
as Russia and Cen al Asian coun ies). Howe e , using a hie a -
chical clus e analysis, Fenge (2007) showed ha , based on simi-
la i ies on go e nmen spending, social si ua ion and poli ical
pa icipa ion, hese coun ies could be di ided in he ollowing
way:
(i) Fo me USSR, wi h gene ally low go e nmen al spending on
social p og ams, mos ly financed h ough social
con ibu ions;
(ii) Pos -Communis Eu opean, e y simila o he fi s ype, bu
wi h highe le els o economic g ow h, infla ion, social well-
being and egali a ianism (Fenge , 2007).
I is impo an o no e ha hese cha ac e is ics do no neces-
sa ily desc ibe he coun ies in absolu e; in ac , mos coun ies
ha e a mix o di e en wel a e egimes, bu none heless ha e
p edominan cha ac e is ics o one ype.
2.3. S a is ical analysis
Da a was analyzed using mul ile el logis ic models based on a
logi -link unc ion wi h a fi s o de quasi-likelihood es ima ion
p ocedu e. The models we e un using MLwiN p og am e sion
2.28 (Rasbash e al., 2013). The da a was analyzed conside ing i s
hie a chical s uc u e in h ee le els: indi iduals (le el 1), nes ed
wi hin yea s (le el 2), nes ed wi hin coun ies (le el 3). O e all
odds, odds a ios, o e all p obabili ies and a e di e ences we e
calcula ed o each wel a e egime. This was based in pa in he
me hods used by Hemmingsson e al. (1999), al hough we applied a
mul ile el modeling echnique.
The use o mul ile el s a is ical echniques allows o he anal-
ysis o he e ec o bo h indi idual and con ex ual a iables on he
ou come o in e es . In his analysis, he con ex ual a iable was
coun y- and yea -specific, making i manda o y o include bo h as
le els. Addi ionally, hese models ake in o accoun he hie a chical
nes ing o indi idual obse a ions wi hin a yea and wi hin a
coun y, co ec ing o he wise unde es ima ed s anda d e o s and
allow he modeling o a iabili y a each le el o analysis
(Sub amanian e al., 2003).
As a sensi i i y analysis, he same models we e un using
di e en es ima ion p ocedu es.
3. Resul s
Table 1 ou lines he dis ibu ion o he a iables among wel a e
egime ypes. Each ype includes be ween wo and se en coun ies,
anging in sample size om 23,310 o 62,509 indi iduals. Coun ies
wi h a Scandina ian wel a e egime had he lowes p opo ion o
people epo ing bad o e y bad heal h (5.4%), ollowed by Anglo-
Saxon (5.8%), Bisma ckian (6.9%), Sou he n (11.9%), Pos -
Communis Eu opean (14.5%) and Fo me USSR (19.6%).
Mos esponden s had achie ed a highe educa ional le el han
hei pa en s: be ween 49.3 and 63.2% had imp o ed in ela ion o
hei mo he , and be ween 45.6 and 61.7% in ela ion o hei a he .
Be ween one hi d and hal o esponden s emained in he same
educa ional le el as hei pa en s and a smalle p opo ion ‘mo ed
down’eonly 1.6% in sou he n coun ies in ela ion o mo he 's
achie emen , up o 12.1% in Bisma ckian coun ies, in ela ion o
a he 's.
Table 2 shows he coe ficien s o he mobili y a iable (s able,
upwa d, downwa d) om he mul ile el models. The ull models
a e a ailable in Tables 3 and 4 as an online supplemen . The gene al
pa e n o associa ion be ween social mobili y and heal h was
simila ac oss all egime ypes, i.e. upwa d mobili y was p o ec i e,
while downwa d mobili y was de imen al o sel - a ed heal h.
Figs. 2 and 3 show he p obabili ies and isk di e ences in he
di e en mobili y g oups in each wel a e egime ype. As was no ed
in Table 1, he o e all p obabili y o bad sel - a ed heal h di e s
significan ly be ween wel a e egime ypes. The benefi s o upwa d
mobili y a e p esen in all egime ypes, bu isk di e ences a e
pa icula ly high o Sou he n, Pos Communis Eu opean and
Fo me USSR egimes and significan ly di e en only in he la e .
Scandina ian coun ies showed he lowes isk di e ences be-
ween upwa dly mobile and s able indi iduals when conside ing
ei he mo he s' o a he s' educa ion.
Downwa d mobili y is gene ally de imen al. Pos Communis
Eu opean coun ies show he bigges absolu e di e ences, wi h
downwa d mobili y leading o an absolu e di e ence o 2.9 and
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248 243
3.6% in he isk o bad heal h measu ed on he basis o ma e nal and
pa e nal achie emen , espec i ely. In Scandina ian, Anglo-Saxon,
Bisma ckian and o me USSR coun ies, his isk di e ence
anges om 0.1 o 1.9%. O e all, Scandina ian coun ies showed he
smalles absolu e di e ence in heal h be ween s able and down-
wa d mobili y when measu ed by he a he 's achie emen , and
o me USSR coun ies when measu ed by he mo he 's.
As a sensi i i y analysis, he same models we e un using
di e en es ima ion p ocedu es (second o de ma ginal quasi-
likelihood, fi s and second o de p edic i e quasi-likelihood and
Ma ko Chain Mon e Ca lo). All esul ed in models wi h he same
e ec o social mobili y in he di e en wel a e egimes. A model
was also un wi h he Gini coe ficien as a le el 2 a iable; his had
e y li le e ec in he odds a ios o isk di e ences and no e ec in
he s a is ical significance o he esul s.
4. Discussion
This s udy sough o desc ibe di e ences in he ela ionship
be ween social mobili y and heal h wi hin di e en wel a e e-
gimes o be e unde s and he e ec ha di e en egime ypes
migh ha e. Di e en wel a e egimes had a subs an ially di e en
p opo ion o indi iduals wi h bad o e y bad sel - a ed heal h,
lowes in coun ies in he Scandina ian egime (5.4%), ollowed by
Anglo-Saxon (5.8%), Bisma ckian (6.9%), Sou he n (11.9%), Pos -
Communis Eu opean (14.5%) and finally Fo me USSR (19.6%).
Table 1
Composi ion o each wel a e ype.
Scandina ian Anglo-Saxon Bisma ckian Sou he n Pos -Communis Eu opean Fo me USSR
Coun ies Denma k
Finland
No way
Sweden
Iceland
Uni ed Kingdom
I eland
Aus ia
Belgium
Swi ze land
Ge many
F ance
Luxembou g
Ne he lands
Spain
G eece
I aly
Po ugal
Czech Republic
Hunga y
Poland
Slo enia
Slo akia
C oa ia
Bulga ia
Es onia
La ia
Li huania Russia
Uk aine
n (le el 2) 23 12 33 18 34 16
n (le el 1) 37,975 23,310 62,509 31,789 51,698 30,072
Le el 1 a iables
% bad o e y bad heal h 5.4 5.8 6.9 11.9 14.5 19.6
Mobili y, mo he (%)
Down 6.3 9.3 4.7 1.6 4.0 9.9
S able 30.4 35.2 32.9 49.0 38.0 29.2
Up 63.2 55.5 62.4 49.3 58.0 60.9
Mobili y, a he (%)
Down 10.1 10.2 12.1 3.4 6.8 9.4
S able 34.6 36.7 42.3 50.9 46.1 28.9
Up 55.4 53.1 45.6 45.6 47.0 61.7
Women (%) 50.0 55.0 52.9 56.6 55.1 61.7
Mean age (yea s) 51.7 51.7 51.6 52.4 51.8 52.7
U ban (%) 64.3 66.0 56.9 65.0 61.3 70.2
Main ac i i y (%)
Paid wo k 63.5 49.7 53.9 48.0 48.9 50.6
No ac i i y 31.3 35.3 32.9 35.5 42.0 42.0
O he 5.2 15.0 13.3 16.5 9.1 7.3
Feeling abou income (%)
Li ing com o ably 49.5 35.4 38.1 15.3 11.3 4.8
Coping 41.4 45.3 46.3 45.0 45.3 37.7
Di ficul 7.0 14.3 12.3 27.7 29.0 37.0
Ve y di ficul 2.0 5.0 3.3 12.1 14.5 20.5
Mino i y (%) 2.4 5.0 4.6 3.0 5.7 12.7
Ma i al s a us (%)
Ma ied 57.5 55.0 59.8 63.7 61.9 52.9
Sepa a ed/di o ced 12.2 11.2 11.9 6.5 9.5 14.7
Widow 7.0 10.9 9.3 12.2 14.2 19.8
Single 23.3 22.9 19.1 17.6 14.3 12.7
Le el 2 a iables
GDP pe capi a (in e na ional dolla s) 39,459 36,705 37,075 26,396 19,924 16,599
No e: ISCED In e na ional S anda d Classifica ion o Educa ion.
Table 2
Mobili y odds a ios and 95% confidence in e als om he mul ile el models in each wel a e egime ype.
Scandina ian Anglo-Saxon Bisma ckian Sou he n Pos -Communis Eu opean Fo me USSR
Mo he n (le el 1) 30,458 19,752 53,644 29,030 46,556 24,959
S able 11111 1
Down 1.39 (1.06,1.83) 1.40 (1.11,1.78) 1.09 (0.89,1.31) 0.72 (0.43,1.21) 1.35 (1.13,1.60) 1.01 (0.84,1.22)
Up 0.77 (0.68,0.86) 0.70 (0.60,0.81) 0.77 (0.71,0.84) 0.56 (0.49,0.62) 0.69 (0.65,0.75) 0.67 (0.61,0.74)
Fa he n (le el 1) 29,837 19,184 52,326 28,417 45,500 23,036
S able 11111 1
Down 1.18 (0.95,1.45) 1.51 (1.19,1.91) 1.20 (1.06,1.37) 1.24 (0.92,1.68) 1.45 (1.28,1.65) 1.17 (0.98,1.39)
Up 0.76 (0.67,0.86) 0.68 (0.59,0.79) 0.76 (0.69,0.82) 0.57 (0.51,0.64) 0.73 (0.68,0.78) 0.68 (0.62,0.75)
No e: bold indica es OR significan a p <0.05.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248244
This di e ence was ep oduced in he mul ile el models, which
con olled o se e al socioeconomic indi idual and coun y
cha ac e is ics.
Bo h on a ela i e and on an absolu e scale, upwa d mobili y was
associa ed wi h be e heal h, ega dless o wel a e egime ype.
Howe e , on he ela i e scale, hese we e significan o all egime
ypes, whe eas on he absolu e scale he e was only a ue di e -
ence in coun ies om he Fo me USSR. Downwa d mobili y was
gene ally associa ed wi h wo se heal h, bu o di e ing ex en s and
ollowing a less clea pa e n.
I has been a gued be o e ha he use o only absolu e o ela i e
measu es can be misleading, and ou findings ei e a e his a gu-
men (King e al., 2012; Kelly e al., 2007). In ac , ela i e measu es
o heal h inequali ies a e insensi i e o equip opo iona e changes,
while absolu e measu es a e insensi i e o uni o m changes, which
eflec s di e en equi y alue judgmen s implied in he empi ical
analysis (Allanson and Pe ie, 2013). Thus, di e en esul s be ween
ela i e and absolu e scales migh be a consequence o di e en
le els o o e all ill-heal h: o me USSR coun ies had he highes
p e alence o bad o e y bad sel - a ed heal h, making absolu e
di e ences mo e likely o eme ge.
This s udy is sensible o a numbe o limi a ions. The ou come
measu e, sel - a ed heal h, is e y cul u ally-sensi i e, compli-
ca ing c oss-na ional compa isons (Jylh€
a e al., 1998). Ne e heless,
i is an impo an p edic o o mo ali y in e e y socie y whe e i
has been examined (Idle and Benyamini, 1997), making i a much
used and alued heal h measu e. Addi ionally, social mobili y
doesn' ha e a unanimously accep ed ope a ionaliza ion. Di e -
ences in educa ional achie emen a e no necessa ily a eflec ion o
di e en socie al p es ige o access o di e en social esou ces.
Indeed, occupa ional mobili y is o en p e e ed (Belle and Hou ,
2006), bu he occupa ional measu es a ailable in he ESS we e
c ude and di ficul o compa e be ween esponden s and hei
pa en s. Also impo an ly, al hough he analyses con olled o
pa en al educa ion, his ope a ionaliza ion o social mobili y migh
be measu ing p ocesses o accumula ion. The wel a e egime
classifica ion is also deba able. Al hough mos o he egime ypes
ha we e used in his s udy ha e been ex ensi ely used be o e, and
despi e bo h le el 2 and le el 3 a iabili y being e y low and non-
significan (hin ing o a high homogenei y be ween coun ies and
coun y-yea s), hey migh no eflec he cha ac e is ics o wel a e
egimes ha ha e an impac on he ela ionship be ween social
mobili y and heal h. Finally, i is no possible o assess causali y
be ween social mobili y and heal h, conside ing ha ou analyses
a e based on c oss-sec ional da a. Indeed, i is possible ha he
heal h o pa icipan s in ou sample was al eady a ec ed by
mobili y in he p e ious ime pe iod. The associa ion be ween
heal h and socioeconomic s a us is likely dynamic and bi-
di ec ional ac oss he li e cou se.
O e all, i is in e es ing o no e ha al hough all wel a e egime
ypes show ela i e di e ences in bad sel - a ed heal h o up-
wa dly mobile indi iduals, on an absolu e scale he Scandina ian
egime shows he smalles di e ences and he o me USSR g oup
he la ges . Al hough wel a e egime ype seems o accoun o an
impo an pa o he a ia ion in sel -pe cei ed heal h among
Eu opean coun ies (Eikemo e al., 2008b), he ex en o which i
impac s heal h inequali ies has been ques ioned. Mackenbach e al.
(2008) epo ed a su p isingly high deg ee o heal h inequali ies in
no he n Eu opean coun ies, showing ha , despi e egali a ian
policies, li es yle- ela ed isk ac o s emain an impo an cause o
mo ali y inequali ies (Mackenbach e al., 2008). Eikemo e al.
(2008a) also showed a clea g adien o heal h inequali ies
Table 3
Mul ile el models: mobili y om mo he 's educa ion.
Scandina ian Anglo-Saxon Bisma ckian Sou he n Pos communis Fo me USSR
n (le el 1) 30,458 19,752 53,644 29,030 46,556 24,959
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Fixed Pa ame e s
In e cep 0.008 (0.005,0.012) 0.009 (0.006,0.027) 0.011 (0.007,0.018) 0.019 (0.009,0.037) 0.016 (0.011,0.022) 0.036 (0.026,0.050)
Indi idual Le el
Mobili y ( e e ence: s able)
Down 1.39 (1.06,1.83) 1.40 (1.11,1.78) 1.09 (0.89,1.31)* 0.72 (0.43,1.21)* 1.35 (1.13,1.60) 1.01 (0.84,1.22)*
Up 0.77 (0.68,0.86) 0.70 (0.60,0.81) 0.77 (0.71,0.84) 0.56 (0.49,0.62) 0.69 (0.65,0.75) 0.67 (0.61,0.74)
Gende ( e : male) 1.03 (0.92,1.15)* 0.89 (0.77,1.02)* 1.07 (0.98,1.15)* 1.59 (1.45,1.75) 1.06 (0.99,1.13)* 1.21 (1.12,1.32)
Age 0.99 (0.99,1.00)* 1.00 (0.99,1.01)* 1.01 (1.01,1.01) 1.04 (1.04,1.05) 1.04 (1.04,1.04) 1.05 (1.04,1.05)
Domicile ( e : u ban) 0.94 (0.84,1.05)* 0.85 (0.74,0.98) 0.88 (0.82,0.95) 1.14 (1.05,1.24) 1.11 (1.04,1.18) 0.97 (0.89,1.05)*
Main ac i i y ( e : paid wo k)
No ac i i y 6.29 (5.39,7.35) 6.17 (5.00,7.61) 4.35 (3.90,4.84) 2.54 (2.22,2.89) 3.35 (3.06,3.67) 2.63 (2.35,2.93)
O he 2.83 (2.21,3.62) 2.55 (1.96,3.31) 1.82 (1.59,2.09) 1.91 (1.64,2.21) 1.97 (1.74,2.24) 1.56 (1.31,1.86)
Income ( e : li ing com o ably)
Coping 1.40 (1.24,1.59) 1.49 (1.26,1.78) 1.52 (1.38,1.67) 1.38 (1.15,1.64) 1.55 (1.33,1.81) 1.10 (0.84,1.45)*
Di ficul 2.97 (2.49,3.54) 2.61 (2.12,3.21) 3.29 (2.94,3.68) 2.28 (1.90,2.73) 3.00 (2.57,3.51) 1.76 (1.35,2.29)
Ve y di ficul 4.57 (3.56,5.86) 4.09 (3.18,5.27) 5.21 (4.47,6.06) 3.97 (3.28,4.82) 5.37 (4.55,6.32) 2.86 (2.19,3.75)
Mino i y ( e : no) 1.44 (1.05,1.97) 0.86 (0.61,1.21)* 1.27 (1.08,1.49) 1.03 (0.79,1.34)* 0.97 (0.86,1.09)* 1.02 (0.91,1.15)*
Ma i al s a us ( e : ma ied)
Sepa a ed/di o ced 1.37 (1.18,1.59) 2.02 (1.67,2.43) 1.28 (1.14,1.42) 1.23 (1.03,1.47) 1.03 (0.93,1.14)* 1.28 (1.14,1.43)
Widow 1.07 (0.89,1.27)* 1.13 (0.92,1.37)* 1.08 (0.97,1.21)* 1.06 (0.95,1.17)* 1.06 (0.98,1.14)* 1.18 (1.08,1.30)
Single 1.02 (0.87,1.19)* 1.19 (0.99,1.43)* 1.17 (1.05,1.31) 1.29 (1.12,1.51) 1.09 (0.97,1.21)* 1.31 (1.13,1.52)
Mo he 's educa ion ( e : ISCED V/VI)
ISCED I 2.39 (1.76,3.26) 1.63 (1.18,2.25) 2.14 (1.66,2.77) 1.23 (0.79,1.92)* 2.48 (1.93,3.21) 2.02 (1.68,2.43)
ISCED II 2.00 (1.49,2.71) 1.25 (0.91,1.72)* 1.72 (1.34,2.21) 0.67 (0.39,1.13)* 1.89 (1.48,2.41) 1.76 (1.45,2.12)
ISCED III 1.67 (1.25,2.23) 1.20 (0.82,1.77)* 1.34 (1.04,1.71) 1.03 (0.62,1.71)* 1.26 (0.99,1.59)* 1.25 (1.04,1.49)
ISCED IV 1.64 (1.04,2.59) 0.37 (0.17,0.79) 1.58 (1.09,2.27) 0.53 (0.15,1.88)* 1.54 (1.05,2.26) 1.12 (0.91,1.38)*
Le el 2
GDP 0.99 (0.99,1.00)* 0.99 (0.99,1.00)* 1.00 (0.99,1.00)* 0.99 (0.99,0.99) 0.99 (0.99,0.99) 0.99 (0.99,0.99)
Random Pa ame e s
Le el 3 a iance (
s
o
) 0.08 (0.06)* 0.19 (0.19)* 0.22 (0.12)* 0.23 (0.17)* 0.07 (0.04)* 0.03 (0.02)*
Le el 2 a iance (
s
uo
) 0.01 (0.01)* 0 (0) 0 (0) 0.01 (0.01)* 0.03 (0.01) 0.01 (0.01)*
No es: * no significan a p <0.05. ISCED In e na ional S anda d Classifica ion o Educa ion. OR Odds a io. CI Confidence in e al.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248 245
be ween Eu opean wel a e s a es, om Sou he n (wi h he highes
inequali ies) o Bisma ckian (wi h he lowes ) (Eikemo e al.,
2008a). This ‘pa adox’was examined by Mackenbach (2012), who
pos ula ed ha social mobili y migh be one o he d i e s o heal h
inequali ies in Wes e n Eu opean wel a e s a es. Some s udies ha e
indeed shown ha inc eased social mobili y is associa ed wi h
s onge heal h inequali ies (Simons e al., 2013;
Asgei sd
o i and
Ragna sd
o i , 2013; Els ad, 2001). Howe e , B ekke, G un eld and
K e ndokk (2014), showed ha highe heal h inequali ies in mo e
egali a ian coun ies migh be solely a consequence o a mo e equal
heal h dis ibu ion, since he concen a ion index is mo e sensi i e
o heal h-con ingen income ans e s han o income-con ingen
heal h ans e s (B ekke e al., 2012).
Ou findings sugges ha some wel a e s a es a e in ac mo e
Table 4
Mul ile el models: mobili y om a he 's educa ion.
Scandina ian Anglo-Saxon Bisma ckian Sou he n Pos communis Fo me USSR
Le el 1 n 29,837 19,184 52,326 28,417 45,500 23,036
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Fixed Pa ame e s
In e cep 0.009 (0.007,0.014) 0.009 (0.005,0.019) 0.013 (0.009,0.018) 0.014 (0.008,0.024) 0.017 (0.013,0.023) 0.033 (0.023,0.047)
Indi idual Le el
Mobili y ( e e ence: s able)
Down 1.18 (0.95,1.45)* 1.51 (1.19,1.91) 1.20 (1.06,1.37) 1.24 (0.92,1.68)* 1.45 (1.28,1.65) 1.17 (0.98,1.39)*
Up 0.76 (0.67,0.86) 0.68 (0.59,0.79) 0.76 (0.69,0.82) 0.57 (0.51,0.64) 0.73 (0.68,0.78) 0.68 (0.62,0.75)
Gende ( e : male) 1.03 (0.92,1.15)* 0.89 (0.77,1.03)* 1.05 (0.97,1.14)* 1.56 (1.42,1.72) 1.07 (1.00,1.14) 1.26 (1.15,1.37)
Age 0.99 (0.99,1.00)* 1.00 (0.99,1.01)* 1.01 (1.01,1.01) 1.04 (1.04,1.05) 1.04 (1.04,1.04) 1.05 (1.04,1.05)
Domicile ( e : u ban) 0.95 (0.85,1.06)* 0.88 (0.76,1.02)* 0.88 (0.82,0.95) 1.14 (1.04,1.24) 1.11 (1.04,1.18) 0.95 (0.87,1.03)*
Main ac i i y ( e : paid wo k)
No ac i i y 6.11 (5.23,7.14) 5.87 (4.76,7.24) 4.44 (3.97,4.95) 2.54 (2.22,2.91) 3.29 (2.99,3.60) 2.70 (2.41,3.04)
O he 2.67 (2.07,3.45) 2.47 (1.89,3.22) 1.19 (1.64,2.17) 1.94 (1.67,2.26) 1.91 (1.68,2.17) 1.58 (1.32,1.90)
Income ( e : li ing com o ably)
Coping 1.41 (1.24,1.61) 1.45 (1.21,1.72) 1.50 (1.36,1.65) 1.35 (1.13,1.61) 1.55 (1.32,1.81) 1.08 (0.82,1.43)*
Di ficul 2.86 (2.39,3.42) 2.54 (2.06,3.13) 3.25 (2.90,3.65) 2.24 (1.87,2.69) 2.94 (2.51,3.45) 1.71 (1.29,2.26)
Ve y di ficul 4.66 (3.62,6.01) 3.74 (2.89,4.85) 5.05 (4.33,5.90) 3.94 (3.24,4.78) 5.31 (4.49,6.27) 2.83 (2.13,3.76)
Mino i y ( e : no) 1.46 (1.06,2.01) 0.97 (0.69,1.35)* 1.33 (1.13,1.57) 1.03 (0.79,1.35)* 0.97 (0.86,1.09)* 1.01 (0.89,1.15)*
Ma i al s a us ( e : ma ied)
Sepa a ed/di o ced 1.42 (1.34,1.96) 2.06 (1.69,2.49) 1.26 (1.13,1.41) 1.23 (1.03,1.48) 1.04 (0.93,1.16)* 1.25 (1.11,1.42)
Widow 1.08 (0.84,1.34)* 1.17 (0.96,1.43)* 1.06 (0.95,1.19)* 1.06 (0.95,1.18)* 1.07 (0.99,1.16)* 1.18 (1.07,1.30)
Single 1.03 (0.88,1.22)* 1.19 (0.99,1.44)* 1.15 (1.03,1.29) 1.31 (1.13,1.53) 1.08 (0.96,1.21)* 1.15 (0.98,1.35)*
Educa ion ( e : ISCED V/VI)
ISCED I 2.18 (1.70,2.79) 1.59 (1.19,2.12) 1.92 (1.61,2.28) 1.70 (1.24,2.33) 2.27 (1.87,2.74) 2.12 (1.77,2.54)
ISCED II 1.67 (1.29,2.16) 1.09 (0.82,1.45)* 1.59 (1.34,1.88) 1.33 (0.94,1.89)* 1.72 (1.44,2.06) 1.79 (1.49,2.15)
ISCED III 1.42 (1.13,1.78) 1.16 (0.82,1.64)* 1.36 (1.17,1.57) 0.99 (0.68,1.47)* 1.21 (1.02,1.43) 1.39 (1.17,1.67)
ISCED IV 1.67 (1.21,2.29) 0.93 (0.54,1.62)* 1.26 (0.98,1.61)* 1.11 (0.52,2.38)* 0.83 (0.58,1.18)* 1.17 (0.94,1.45)*
Le el 2
GDP 0.99 (0.99,1.00)* 1.00 (0.99,1.00)* 1.00 (0.99,1.00)* 0.99 (0.99,0.99) 0.99 (0.99,0.99) 0.99 (0.99,0.99)
Random Pa ame e s
Le el 3 a iance (
s
o
) 0.09 (0.07)* 0.19 (0.19)* 0.21 (0.12)* 0.24 (0.17)* 0.08 (0.05)* 0.03 (0.02)*
Le el 2 a iance (
s
uo
) 0.01 (0.01)* 0 (0) 0 (0) 0.003 (0.004)* 0.03 (0.01) 0.01 (0.01)*
No es:* no significan a p <0.05. ISCED In e na ional S anda d Classifica ion o Educa ion. OR Odds a io. CI Confidence in e al.
Fig. 2. P obabili y o ‘Bad’o ‘Ve y Bad’sel - a ed heal h pe o mobili y g oup, defined om mo he 's educa ional achie emen , pe wel a e ype (e o ba s a e 95% confidence
in e als) and isk di e ence.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248246
e ec i e in sepa a ing social mobili y om heal h, namely Scan-
dina ian coun ies exhibi smalle di e ences while o me USSR
socie ies he la ges . This is no su p ising conside ing ha , o
example, comp ehensi e social policies seem o be associa ed wi h
ewe inequali ies in ‘sickness’in Eu opean coun ies, as well as
lowe a es o non-employmen ( an de Wel e al., 2011). I is
unde s andable hen, ha Scandina ian coun ies will manage o
disassocia e social mobili y om heal h mo e e ec i ely, leading o
he small isk di e ences we ound o upwa d mobili y in hese
coun ies.
Impo an ly oo, Cen al and Eas e n Eu opean coun ies un-
de wen conside able ansi ions in he las decades, wi h impo -
an consequences o hei social s uc u es (Saa e al., 2012). Ou
esul s o he pos -Communis Eu opean and o me USSR wel a e
egimes, which ended o show he la ges absolu e di e ences in
heal h, migh eflec , a leas pa ially, hese impo an s uc u al
changes and no jus ela i e social mobili y.
Ou findings also ein o ce he need o assess heal h inequali ies
using bo h ela i e and absolu e measu es, since he use o only one
migh be e y misleading.
In e es ingly oo, when compa ing he associa ion o downwa d
mobili y wi h heal h as assessed in e e ence o pa e nal e sus
ma e nal achie emen , he o me was la ge in e e y wel a e
egime excep he Scandina ian egion. Conside ing ha Scandi-
na ian coun ies ha e he bes indica o s o gende equali y
(Eu opean Ins i u e o Gende Equali y, 2013), a possible expla-
na ion o his is ha in o he , less gende -egali a ian coun ies, he
a he 's s a us is mo e decisi e in de e mining he amily's socio-
economic s a us, and he e o e a downwa d mobili y om his so-
cial posi ion has a g ea e impac .
To he bes o ou knowledge, his is he fi s esea ch in o he
mode a ing e ec o wel a e egimes on he ela ionship be ween
social mobili y and heal h, and o measu e social mobili y sepa a ely
based on ma e nal and pa e nal achie emen . Fu he explo a ion o
ou findings would benefi om measu ing occupa ional social
mobili y in addi ion o educa ional mobili y. I would also benefi
om a sepa a e analysis o each gende , since he e ec migh be
di e en o women and men and migh help explain he di e ences
in he associa ion o downwa d mobili y when measu ed on he
basis o ma e nal and pa e nal achie emen .
P e ious s udies ha e ques ioned he con ibu ion o he
wel a e egime in mi iga ing he ex en o heal h inequali ies and
iden ified inc eased social mobili y as a possible cause o his
(Mackenbach, 2012). Howe e , he p esen esul s show ha
impo an sys ema ic di e ences exis be ween egime ypes wi h
ega d o upwa d mobili y and heal h, wi h a no ably a enua ed
associa ion on he absolu e scale in Scandina ian coun ies and
s onge associa ion in he o me USSR egimes. This sugges s ha
social mobili y is no a cause o high heal h inequali ies ound in
Scandina ian coun ies in p e ious analyses.
Acknowledgmen s
I. Campos Ma os is suppo ed by a Fulb igh g an o Public
Heal h esea ch, awa ded by he U.S. Depa men o S a e and he
Po uguese Go e nmen , and by a s uden ship om he Po uguese
Founda ion o Science and Technology.
Appendix A. Supplemen a y da a
Supplemen a y da a ela ed o his a icle can be ound a h p://
dx.doi.o g/10.1016/j.socscimed.2015.08.035.
Re e ences
Allanson, P., Pe ie, D., 2013. On he choice o heal h inequali y measu e o he
longi udinal analysis o income- ela ed heal h inequali ies. Heal h Econ. 22 (3),
353e365.
Asgei sd
o i , T.L., Ragna sd
o i , D.
O., 2013. De e minan s o ela i e and absolu e
concen a ion indices: e idence om 26 Eu opean coun ies. In . J. Equi y
Heal h 12, 53.
Bamb a, C., 2007. ‘Si ing he whea om he Cha ’: a wo-dimensional disc imi-
nan analysis o wel a e s a e egime heo y. Soc. Policy &Adm. 41 (1), 1e28.
Belle , E., Hou , M., 2006. Wel a e s a es and social mobili y: how educa ional and
social policy may a ec c oss-na ional di e ences in he associa ion be ween
occupa ional o igins and des ina ions. Res. Soc. S a i . Mobil. 24 (4), 353e365.
Bonoli, G., 1997. Classi ying wel a e s a es: a wo-dimension app oach. J. Soc. policy
26 (03), 351e372.
B ekke, K.A., G un eld, L., K e ndokk, S., 2012. Asymme ic Impac s o T ans e s o
he Concen a ion Index: Explaining he Heal h Equali y Pa adox. HERO. Uni-
e si y o Oslo.
Case, A., Paxson, C., 2008. Heigh , heal h, and cogni i e unc ion a olde ages. Am.
Econ. Re . 98 (2), 463.
Cook, L., 2010. In: P ess, O.U. (Ed.), Eas e n Eu ope and Russia. The Ox o d Hand-
book o The Wel a e S a e, New Yo k.
Eikemo, T.A., Huisman, M., Bamb a, C., Kuns , A.E., 2008. Heal h inequali ies ac-
co ding o educa ional le el in di e en wel a e egimes: a compa ison o 23
Fig. 3. P obabili y o ‘Bad’o ‘Ve y Bad’sel - a ed heal h pe o mobili y g oup, defined om a he 's educa ional achie emen , pe wel a e ype (e o ba s a e 95% confidence
in e als) and isk di e ence.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248 247
Eu opean coun ies. Sociol. Heal h &Illn. 30 (4), 565e582.
Eikemo, T.A., Bamb a, C., Judge, K., Ringdal, K., 2008. Wel a e s a e egimes and
di e ences in sel -pe cei ed heal h in Eu ope: a mul ile el analysis. Soc. Sci.
Med. 66 (11), 2281e2295.
Els ad, J.I., 2001. Heal h- ela ed mobili y, heal h inequali ies and g adien cons ain
discussion and esul s om a No wegian s udy. Eu . J. Public Heal h 11 (2),
135e140.
Espig Ande sen, G., 1990. In: Dona i, P., P andini, R. (Eds.), The Th ee Wo lds o
Wel a e Capi alism, Ci .
ESS ERIC, 2014. Abou he Eu opean Social Su ey Eu opean Resea ch In as uc u e
eESS ERIC [ci ed 2014 Ap il 22nd]. A ailable om: h p://www.
eu opeansocialsu ey.o g/abou /index.h ml.
Eu opean Ins i u e o Gende Equali y, 2013. Gende Equali y Index: Coun y
P ofiles.
Eu os a , 2014. Gini Coe ficien o Equi alised Disposable Income [ci ed 2014 Ma ch
30]. A ailable om: h p://ec.eu opa.eu/eu os a / gm/ able.do?
ab¼ able&ini ¼1&language¼en&pcode¼ essi190&plugin¼1.
Fa a o, A., San onas aso, P., 1995. E ec s o pa en s' psychological cha ac e is ics
and ea ing beha iou on childhood obesi y and die a y compliance.
J. Psychosom. Res. 39 (2), 145e151.
Fenge , H., 2007. Wel a e egimes in cen al and Eas e n Eu ope: inco po a ing
pos -communis coun ies in a wel a e egime ypology. Con emp. Issues Ideas
Soc. Sci. 3 (2).
Fe e a, M., 1996. The'Sou he n model'o wel a e in social Eu ope. J. Eu . Soc. policy
6 (1), 17e37.
Galoba des, B., Shaw, M., Lawlo , D.A., Lynch, J.W., Smi h, G.D., 2006. Indica o s o
socioeconomic posi ion (pa 1). J. Epidemiol. Commun. Heal h 60 (1), 7e12.
Hallq is , J., Lynch, J., Ba ley, M., Lang, T., Blane, D., 2004. Can we disen angle li e
cou se p ocesses o accumula ion, c i ical pe iod and social mobili y? an
analysis o disad an aged socio-economic posi ions and myoca dial in a c ion
in he S ockholm Hea Epidemiology P og am. Soc. Sci. Med. 58 (8),
1555e1562.
Hemmingsson, T., Lundbe g, I., Dide ichsen, F., 1999. The oles o social class o
o igin, achie ed social class and in e gene a ional social mobili y in explaining
social-class inequali ies in alcoholism among young men. Soc. Sci. Med. 49 (8),
1051e1059.
Idle , E.L., Benyamini, Y., 1997. Sel - a ed heal h and mo ali y: a e iew o wen y-
se en communi y s udies. J. Heal h Soc. Beha . 21e37.
Jylh€
a, M., Gu alnik, J.M., Fe ucci, L., Jokela, J., Heikkinen, E., 1998. Is sel - a ed heal h
compa able ac oss cul u es and gende s? Jou nals Ge on ology Se . B Psychol.
Sci. Soc. Sci. 53 (3), S144eS152.
Kelly M.P., Wo ld Heal h O ganiza ion Commission on he Social De e minan s o
Heal h and Bonne oy J., The Social De e minan s o Heal h: De eloping an E -
idence Base o Poli ical Ac ion, 2007, Uni e sidad del Desa ollo, Chile, and
Na ional Ins i u e o Heal h and Clinical Excellence, Uni ed Kingdom.
King, N.B., Ha pe , S., Young, M.E., 2012. Use o ela i e and absolu e e ec measu es
in epo ing heal h inequali ies: s uc u ed e iew. BMJ 345 e5774.
Libe a os, P., Link, B.G., Kelsey, J.L., 1988. The measu emen o social class in
epidemiology. Epidemiol. Re . 10 (1), 87e121.
Mackenbach, J.P., S i bu, I., Roskam, A.J.R., Schaap, M.M., Men ielle, G., Leinsalu, M.,
Kuns , A.E., 2008. Socioeconomic inequali ies in heal h in 22 Eu opean coun-
ies. N. Engl. J. Med. 358 (23), 2468e2481.
Mackenbach, J.P., 2012. The pe sis ence o heal h inequali ies in mode n wel a e
s a es: he explana ion o a pa adox. Soc. Sci. Med. 75 (4), 761e769.
Ma mo , M., 2004. Men and women beha ing badly? In: Macmillan (Ed.), The
S a us Synd ome: How Social S anding A ec s Ou Heal h and Longe i y. New
Yo k.
Ma mo , M., Wilkinson, R., 2005. Social De e minan s o Heal h. Ox o d Uni e si y
P ess.
Rasbash, J., Cha l on, C., B owne, W.J., Healy, M., Came on, B., 2013. MLwiN Ve sion
2.28. Cen e o Mul ile el Modelling, Uni e si y o B is ol.
Saa , E., Un , M., 2012. Labou ma ke e u ns o e ia y educa ion in pos -socialis
coun ies. In: Lambe , P. (Ed.), Social S a ifica ion: T ends and P ocesses.
Ashga e Publishing, L d, England.
Simons, A.M., G o en, D.A., Bosma, H., 2013. Socio-economic inequali ies in all-
cause mo ali y in Eu ope: an explo a ion o he ole o heigh ened social
mobili y. Eu . J. Public Heal h ck 145.
Singhamme , J., Mi elma k, M.B., 2010. S anda d measu es o in e -gene a ional
social mobili y dis o ac ual pa e ns o mobili y and heal h beha iou : e i-
dence o a be e me hodology. C i . Public Heal h 20 (2), 223e232.
Sub amanian, S., Jones, K., Duncan, C., 2003. Mul ile el Me hods o Public Heal h
Resea ch: Neighbo hoods and Heal h. Ox o d Uni e si y P ess, New Yo k.
an de Wel, K.A., Dahl, E., Thielen, K., 2011. Social inequali ies in ‘sickness’: Eu o-
pean wel a e s a es and non-employmen among he ch onically ill. Soc. Sci.
Med. 73 (11), 1608e1617.
Wes , P., 1991. Re hinking he heal h selec ion explana ion o heal h inequali ies.
Soc. Sci. Med. 32 (4), 373e384.
Wo ld Bank, 2014. GDP pe capi a, PPP (Cu en In e na ional Dolla s) [ci ed 2014
Ma ch 30 h]. A ailable om: h p://da a.wo ldbank.o g/indica o /NY.GDP.PCAP.
PP.CD.
I. Campos-Ma os, I. Kawachi / Social Science & Medicine 142 (2015) 241e248248
Table 1 Desc ip ion o main esul s o eligible publica ions, acco ding o SES a iable and heal h ou come used
Heal h ou come
Medical indica o s Func ional indica o s Subjec i e heal h
Socioeconomic
de e minan s
Place o esidence Physical heal h ended o be
be e among u al adolescen s
(Machado-Rod igues, 2012,
Machado-Rod igues, 2011) and
less dep i ed neighbo hoods
(Bas os, 2013). Pa en al
pe cep ions o be e
neighbo hood en i onmen s also
ended o show an associa ion
wi h be e physical (Noguei a,
2013a, Machado-Rod igues, 2014)
bu wo se men al heal h
(Ca alho, 2014) among child en.
The only s udy (Nunes, 2010)
showed no associa ion
be ween place o esidence
and cogni i e abili y.
One s udy (Humbold , 2014)
showed ha li e sa is ac ion was
be e in u al a eas.
Race/e hnici y/
cul u e/language
Mig an s showed highe
mo ali y (Ha ding, 2008,
Williamson, 2009), wo se o al
heal h (Pe ei a, 2013) and a
highe pe cen age o small
p e e m bi hs (Ha ding, 2006b).
On he o he hand, mig an
adolescen s had less men al
heal h p oblems (Ne o, 2009
and Ne o, 2010) and be e
ca dio espi a o y i ness
(San os, 2011).
The e we e di e ences in SRH
among na ionali ies in one s udy
(Dias, 2013), bu all o he s udies
showed no associa ion be ween
mig a ion, e hnici y o na ionali y
and subjec i e heal h (Malmusi,
2014 and Humbold , 2014).
Occupa ion Mos s udies showed a s ong
associa ion be ween
unemploymen o less
di e en ia ed occupa ions and
wo se heal h (see, o example,
F aga, 2014 o San os, 2008),
al hough some ound no
associa ion ( o example Al es,
2012 o Bas os, 2013). None
ound an opposi e esul .
One s udy (Aze edo, 2012) ound
people who we e unemployed
o e i ed we e mo e likely o
su e om ch onic pain.
Sil a (2014) showed s ong
associa ions be ween
employmen and mo e
di e en ia ed occupa ions wi h
SRH. On he o he hand,
Humbold (2014) ound no
associa ion be ween
employmen and li e sa is ac ion.
Gende /sex Almos all s udies showed an
associa ion be ween being
emale and wo se heal h (see,
o example, San os, 2011 o
Bulhões, 2013). Some s udies
ound no gende di e ences
(see, o example, Bas os, 2013 o
Ne o, 2010) and wo ound he
opposi e associa ion (Pe elman,
2012 and S ewa -Knox, 2012).
Women we e mo e likely o ake
sickness absence (Mas e kaasa,
2014 and Pe elman, 2012) and
epo ch onic pain (Aze edo,
2012 and Pe elman, 2012), and
one s udy showed men epo ed
mo e bed days (Pe elman, 2012).
Cogni i e abili ies di e ed
be ween gende s, depending on
he es used (Ma ins, 2012,
San os, 2014a).
Almos e e y s udy showed
women had wo se subjec i e
heal h ou comes (see, o
example, Bamb a, 2009, Dias,
2013 o Pe ei a, 2011).
Religion One s udy showed no
associa ion be ween eligion o
spi i uali y and he onse o
majo dep ession (Leu en , 2013).
One s udy showed eligious
people showed highe li e
sa is ac ion (Humbold , 2014),
and ano he showed no
associa ion be ween eligion o
spi i uali y and quali y o li e o
well-being (Vilhena, 2014).
Educa ion Lowe educa ion ended o show
a s ong associa ion wi h wo se
heal h in almos all s udies (see,
o example, Bas os, 2013 o
San os, 2010). The e we e wo
excep ions: Lawlo , 2005, who
showed ha insulin esis ance
was mo e common in child en
o mo e educa ed pa en s and
Cos a, 2008, who showed gi ls
whose pa en s we e mo e
Educa ion was s ongly
associa ed wi h cogni i e abili y
(Ma ins, 2012, Nunes, 2010 and
San os, 2014a), ch onic pain
(Aze edo, 2012) and unc ional
limi a ions (Eikemo, 2008,
Knesebeck, 2006).
Be e SRH was associa ed wi h
highe educa ion in all s udies
(see, o example, Knesebeck,
2006 o Sil a, 2014) excep one,
ha showed he opposi e
(Humbold , 2014).
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 5 o 10
Table 1 Desc ip ion o main esul s o eligible publica ions, acco ding o SES a iable and heal h ou come used (Con inued)
educa ed had mo e ea ing
diso de symp oma ology.
Socioeconomic
s a us
Ma ied indi iduals ended o
show be e heal h ou comes
(see, o example, Ha ding, 2008
o Williamson, 2009), bu had
highe odds o being obese
(Al es, 2012 and Goulão, 2015).
Income, dep i a ion and inancial
di icul ies showed con lic ing
esul s: while mos s udies
ended o show wo se heal h
ou comes o mo e dep i ed
people (see, o example, Pe ei a,
2013 o Al es, 2012) o no
associa ion a all (see, o
example, Co eia, 2014 o
Pimen a, 2011), he e we e some
excep ions ha showed, o
example, lowe p e alence o
obesi y among homeless people
(Oli ei a, 2012) o mo e insulin
esis ance among child en wi h
iche pa en s (Lawlo , 2005).
One s udy (Aze edo, 2012) ound
no associa ion be ween ma i al
s a us and ch onic pain. Ea ly li e
SES, as measu ed by heigh , was
s ongly associa ed wi h ch onic
pain in women (Pe elman, 2014).
Objec i e income (Humbold ,
2014, Sil a, 2014) and pe cei ed
income (Dias, 2013) we e ound
o be associa ed wi h subjec i e
heal h, bu no ma i al s a us
(Humbold , 2014) o heigh , as a
measu e o ea ly li e SES
(Pe elman, 2014).
Social capi al One s udy (Fe ei a-Valen e, 2014)
showed ha social suppo was
associa ed wi h be e
psychological unc ioning.
One s udy (Fe ei a-Valen e, 2014)
showed ha social suppo had a
s ong associa ion wi h physical
unc ioning, bu no pain
in ensi y.
Numbe o ac i i ies ou side he
home was he only social capi al
indica o ha showed an
associa ion wi h SRH (Sil a, 2014).
O he analyses showed no
associa ion (Vilhena, 2014,
Sil a, 2014).
No e: no eligible publica ion explo ed he ela ionship be ween ‘ ace/e hnici y/cul u e/language’o ‘ eligion’and unc ional indica o s
Legend: SRH Sel Ra ed Heal h. SES Socioeconomic S a us
Fig. 2 Diag am ep esen ing main esul s o he associa ions ound in he eligible publica ions. The isual aspec o he diag am, bu no he ules o
i s cons uc ion, was based on he diag am buil by Ashley EA e al., “Clinical assessmen inco po a ing a pe sonal genome”The Lance 375(2010):
1525-35. No e: Fon size o heal h ou comes and ci cle size o socioeconomic de e minan s a e p opo ional o he numbe o eligible publica ions in
which hey ea u ed. Black a ows ep esen s ong e idence o an associa ion be ween socioeconomic indica o and heal h ou come; g ey a ows
ep esen weak e idence and dashed a ows ep esen e idence o he “nega i e”associa ions. In he esul s ob ained, “nega i e”includes mig an
popula ions ha ing be e men al heal h and ma ied indi iduals ha ing highe p e alence o obesi y. E idence o all o he associa ions had a “posi i e”
di ec ion, i.e., ill heal h was associa ed wi h lowe educa ion, lowe income, emale gende , unemploymen , dep i a ion, ha ing less di e en ia ed
occupa ions and li ing in an un a ou able o u ban a ea. De ails on how his diag am was cons uc ed a e in he online Addi ional ile 3
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 6 o 10
Educa ion was he mos equen ly s udied de e minan
o heal h and o which mos e idence exis s o heal h in-
equali ies. E idence o educa ional inequali ies in obesi y
was pa icula ly common, especially o women, as he
wo s udies ha s a i ied he analysis by gende ound
only women showed signi ican inequali ies [43, 44]. This
sugges s educa ional inequali ies in o e weigh /obesi y a e
ound mos ly o exclusi ely in women. This is no
unique o Po ugal: Roskam e al. (2010) ound ha
o he sou he n Eu opean coun ies also show high
educa ion inequali ies in o e weigh and obesi y only
o women [57]. In his analysis, Po ugal had he highes
educa ional inequali ies in o e weigh and obesi y among
women in all he coun ies analysed. This can be a conse-
quence o a ious ac o s, such as inequali ies in physical
ac i i y, die a y pa e ns o pa i y. Howe e , bo h men and
women seem o show he same ex en o educa ional in-
equali ies in physical ac i i y and die in Po ugal [58, 59],
which makes hem unlikely ac o s in explaining inequal-
i ies in obesi y seen mos ly in women. On he o he hand,
women wi h lowe educa ion in Po ugal ha e a highe
e ili y index [60], and since highe pa i y is s ongly
associa ed wi h obesi y [61], his migh be he mos
sui able explana ion o he high educa ional inequali ies
in o e weigh and obesi y seen o women in Po ugal.
Educa ion was also s ongly associa ed wi h SRH
[28, 39, 47–49], which is consis en wi h o he in e -
na ional analyses [49, 62]. In e es ingly a Eu opean com-
pa ison among 22 coun ies ound ha Po uguese men
showed he highes educa ion inequali ies in SRH when
compa ed o o he coun ies [49]. Howe e , educa ional in-
equali ies in SRH should be in e p e ed wi h cau ion. As
Huisman, Len he and Mackenbach (2007) poin ed ou , he
p edic i e abili y o SRH o mo ali y a ies signi ican ly
among educa ional g oups o men [63]. This p obably e-
lec s educa ional di e ences in men’s heal h pe cep ion,
biasing he answe s o ques ions on subjec i e heal h.
Ou e iew also sugges ed s ong gende inequali ies in
bo h SRH and men al heal h symp oms. Gende - ela ed
heal h inequali ies is a b oad and complex opic. Despi e
he p e ailing no ion ha men ha e highe mo ali y and
women highe mo bidi y [64], his has been challenged in
he li e a u e, and con adic o y pa e ns con inue o ap-
pea [65, 66]. Addi ionally, gende inequali ies in heal h
a e p obably a esul o mul iple ac o s, including bio-
logical and social [67], which aises ques ions o whe he
hey should be conside ed as un ai o as una oidable.
Despi e his, almos e e y publica ion ha explo ed gen-
de di e ences in ou e iew showed s ongly a ou able
esul s o men, pa icula ly o men al heal h symp oms
and SRH [32]. No iceably, no publica ion explo ed gende
di e ences in mo ali y.
Academic a en ion o heal h inequali ies in Po ugal
has ended o ocus on speci ic opics. Gende and
educa ion a e by a he mos commonly used SES indi-
ca o s, possibly because hey a e he mos easily measu -
able, commonly used in su eys wi h high esponse a es
and high alidi y o answe s and a e less a ec ed by
e e se causa ion. Twel e publica ions also looked a
heal h inequali ies be ween mig an s and Po uguese
na i es; his is su p ising conside ing Po ugal is one o
he Eu opean coun ies wi h he lowes p opo ion o
mig an popula ion among i s esiden s [68]. This could
be impu ed o bo h he ease o measu emen o his
a iable and he p esence o esea ch g oups in he
coun y in es iga ing his subjec .
O he SES indica o s appea o ha e been o e looked.
Fo example, despi e he g owing li e a u e on he e ec
o place in heal h, only a ew publica ions explo ed his
opic, mos o which ocused on u al/u ban di e ences.
The e was also a no able de iciency o s udies o social
capi al and po e y, despi e Po ugal’s high income in-
equali y [6] and conside able isk o po e y and social ex-
clusion [69]. Addi ionally, despi e he g owing ecogni ion
o he ime dimension in he building o heal h inequal-
i ies [70], no publica ion ook a li e cou se app oach o
how SES indica o s migh a ec heal h. This, coupled wi h
he sca ci y o longi udinal s udies, subs an ially p ecludes
he possibili y o assessing causal ela ionships. This also
speaks o a e y sca ce ocus on he elde ly - o he 71 eli-
gible publica ions, only 7 ocused on olde people, which
is su p ising in a coun y whe e he old-age dependency
a io was he i h highes in Eu ope in 2014 [71].
In 2013, he majo causes o dea h in Po ugal we e dis-
eases o he ci cula o y sys em (30), malignan umou s
(24), diseases o he espi a o y sys em (12), and endo-
c ine, nu i ional and me abolic diseases (5 %) [72]. In his
sense, despi e malignan umou s being he second mos
common cause o dea h, a e ci cula o y diseases, he e
a e s ikingly ew publica ions ocusing on his heal h
issue ( ou , o which wo a e ecological). This migh again
e lec he absence o a na ionally o ien ed esea ch policy,
in pa a ibu able o absence o poli ical a en ion o his
issue [3, 4, 8]. This is also he case o espi a o y diseases,
which a e also almos absen om ou analysis. In a ecen
epo o a conso ium published by he Eu opean
Commission on Heal h Inequali ies, Po ugal was de-
sc ibed as ha ing “[clea ] di icul ies in measu ing and
analysing heal h inequali ies”[73] (page 129). In e es -
ingly, he cu en Po uguese Na ional Heal h Plan iden i-
ies he educ ion o child obesi y as one o i s ou goals
o 2020, bu wi h no ocus on i s unequal dis ibu ion
among socioeconomic g oups [74]. This plan does men-
ion he impo ance o he social de e minan s o heal h,
bu ocuses almos exclusi ely on he access o heal h ca e
se ices as a emedy o heal h inequali ies [74].
The limi ed a en ion gi en o heal h inequali ies in
Po ugal can only be explained wi h an ex ensi e
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 7 o 10
explo a ion o mul iple ac o s, bu one o hese ac o s
is p obably he eng ained belie ha he Na ional Heal h
Se ice, as a uni e sal and ( ela i ely) inexpensi e se -
ice a poin o ca e, is enough o ace hese inequali ies.
Howe e , his is appa en ly no ue, as his e iew has
shown he e a e s ill impo an heal h inequali ies in
Po ugal. Tackling hese inequali ies will demand an im-
po an e o o build an o ganized esea ch and policy
s a egy ha will ha e o go beyond he Na ional Heal h
Se ice. I is impo an o no ice ha Po ugal is amongs
he mos unequal coun ies in Eu ope, so ha i could
bene i om a mo e p og essi e axa ion scheme and
highe social p o ec ion o he poo es , which a e majo
e idence-based and consensual measu es o igh inequal-
i ies in heal h [75].
Limi a ions
This e iew ied o b ing oge he analyses no always
compa able among hem. In ac , many o hese publica-
ions ocused on speci ic popula ions –mig an s, child en
o ce ain egions in Po ugal – ha migh ha e pa icula
pa e ns o heal h inequali ies. This migh ha e hidden
inequali ies ha a e no appa en when all g oups a e
pooled oge he . Ou sea ch s a egy migh ha e also
excluded impo an publica ions, namely in e na ional
compa isons ha included a Po uguese sample no
speci ically men ioned. Howe e , we ied o o e come
his by sea ching o publica ions by esea che s known
o ha ing published in his a ea. The quali y o he ana-
lyses in he e iewed publica ions was ound o be he e o-
geneous, wi h some p esen ing highly eliable analyses
and o he s elying on ‘con enience samples’,o onsmall
sample sizes. Following he PRISMA guidelines, we chose
no o sco e no selec he publica ions based on ‘quali y’,
bu o ca y ou a b ie assessmen o s eng hs and limi a-
ions on each ( able in Addi ional ile 2). Also, we ocused
ou e iew on pape s published in indexed pee - e iewed
jou nals acco ding o good p ac ices o scien i ic esea ch,
bu his may ha e excluded impo an publica ions, in
pa icula om he g ey li e a u e.
Finally, we es ic ed ou analysis o heal h ou comes,
and did no conside media ing ac o s such as li es yle
and heal hca e use. Also, we did no conside s udies on
in e en ions o dec ease inequali ies in heal h. We
adop ed his s a egy o a oid a oo la ge scope o he
e iew, which would ha e complica ed he iden i ica ion
o gene al ends and in e p e a ions. Fu he esea ch
should ocus on hese connec ed issues.
Along his pape , we e e ed o “inequali ies”in heal h
ins ead o o he possible e ms such as “inequi y”o
“di e ences”. In pa icula , inequi y e e s o di e ences
ha a e unjus , un ai and a oidable [76]. This op ion
was made because he concep o inequali y is mo e
neu al in e ms o in e p e a ions and alue judgemen s,
whe eas he e m “inequi y”implies s ong assump ions
abou he causes o di e ences, which none o he
e iewed pape s could con i m. Addi ionally, mos
e iewed pape s e e ed o inequali ies in heal h, so we
op ed o be ai h ul o au ho s’in e p e a ions.
Conclusions
We ha e shown ha he e is s ong e idence o socioeco-
nomic heal h inequali ies in Po ugal and compa a i e
analyses show ha hese a e possibly one o he highes
among Eu opean coun ies. We iden i ied educa ion and
gende as he main de e minan s o heal h inequali ies,
a ec ing mos ly he dis ibu ion o obesi y, sel - a ed
heal h and men al heal h symp oms. The publica ions we
iden i ied also e lec he absence o a na ionally o ien ed
esea ch s a egy on heal h inequali ies ocusing on he
mos p e alen diseases (such as malignan umou s and
espi a o y diseases), de e mining ac o s o inequali ies
(li ing con ex s, po e y o social capi al) and ulne able
popula ions (such as he elde ly). We hope his e iew will
help guide decision-making o ackle hese issues, as has
long been ecommended.
Addi ional iles
Addi ional ile 1: De ailed sea ch s a egy. (PDF 79 kb)
Addi ional ile 2: Table o ex ac ed da a om he 71 eligible
publica ions. (PDF 196 kb)
Addi ional ile 3: Desc ip ion o ules adop ed o build diag am in
Fig. 2 o he main ex . (DOCX 16 kb)
Addi ional ile 4: Comple e lis o he se en y one eligible publica ions
iden i ied by he sys ema ic e iew, by alphabe ical o de . (PDF 70 kb)
Compe ing in e es s
The au ho s ha e no compe ing in e es s o decla e.
Au ho s’con ibu ions
ICM con ibu ed o s udy concep ualisa ion and design, da a acquisi ion,
selec ion and analysis, and d a ed he manusc ip . GR con ibu ed o s udy
concep ualisa ion and design, da a selec ion and manusc ip e ision. JP
con ibu ed o s udy concep ualisa ion and design, da a selec ion and
ex ac ion and manusc ip e ision. All au ho s app o ed he inal manusc ip .
Acknowledgemen s
The au ho s wish o hank he con ibu ion o he esea che s om he No a
Heal hca e Ini ia i e, who p o ided commen s on a la e d a o his pape .
The inal pape is he esponsibili y o he au ho s.
This p ojec has been inanced by he Fundação pa a Ciência e Tecnologia
(G an VIH/SAL/0065/2011).
Au ho de ails
1
Ins i u o de Higiene e Medicina T opical, Uni e sidade NOVA de Lisboa,
Lisbon, Po ugal.
2
Cen o de In es igação em Saúde Pública, Lisbon, Po ugal.
3
Global Heal h and T opical Medicine, Ins i u o de Higiene e Medicina
T opical, NOVA Uni e si y o Lisbon, Lisbon, Po ugal.
4
Escola Nacional de
Saúde Pública, Uni e sidade NOVA de Lisboa, Lisbon, Po ugal.
Recei ed: 23 No embe 2015 Accep ed: 1 Feb ua y 2016
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 8 o 10
Re e ences
1. Ma mo M, F iel S, Bell R, Houweling TA, Taylo S. Closing he gap in a
gene a ion: heal h equi y h ough ac ion on he social de e minan s o
heal h. Lance . 2008;372(9650):1661–9.
2. Black D, Mo is J, Smi h C, Townsend P. Inequali ies in heal h: epo o a
Resea ch Wo king G oup. London: Depa men o Heal h and Social
Secu i y; 1980. p. 19.
3. Pe ei a J, Fu ado C. Equidade em saúde: do conhecimen o à acção. In: A
No a Saúde Pública: A saúde Pública na E a do Conhecimen o, edi o .
DGS/ENSP. Lisbon: G adi a; 2011.
4. Wo ld Heal h O ganiza ion. WHO e alua ion o he na ional heal h plan o
Po ugal (2004–2010). Copenhagen: WHO Regional O ice o Eu ope; 2010.
5. Wo ld Heal h O ganiza ion. Po ugal Heal h Sys em Pe o mance
Assessmen . WHO and Al o Comissa iado da Saúde [Po uguese High
Comissione o Heal h]. 2010.
6. Eu opean Commission. Social Si ua ion Moni o - Income inequali y in EU
coun ies. 2015. h p://ec.eu opa.eu/social/main.jsp?ca Id=1050&in PageId=
1870&langId=en. Accessed 22 No embe 2015.
7. Mackenbach JP, S i bu I, Roskam AJ, Schaap MM, Men ielle G, Leinsalu M,
e al. Socioeconomic inequali ies in heal h in 22 Eu opean coun ies.
N Engl J Med. 2008;358(23):2468–81.
8. Bago d’U a T. Equidade no sec o da saúde em Po ugal. In: Almedina E,
edi o . 30 Anos do Se iço Nacional de Saúde - um pe cu so comen ado.
Lisbon: Simões, Jo ge; 2010.
9. Mohe D, Libe a i A, Te zla J, Al man DG. P e e ed epo ing i ems o
sys ema ic e iews and me a-analyses: he PRISMA s a emen . BMJ.
2009;349:g7716.
10. O’Neill J, Tabish H, Welch V, Pe ic ew M, Po ie K, Cla ke M, e al. Applying
an equi y lens o in e en ions: using PROGRESS ensu es conside a ion o
socially s a i ying ac o s o illumina e inequi ies in heal h. J Clin Epidemiol.
2014;67(1):56–64.
11. Blax e M. A compa ison o measu es o inequali y in mo bidi y. Gowe :
Heal h inequali ies in Eu opean coun ies Alde sho ; 1989. p. 199–230.
12. Public Heal h Ins i u e o he Uni e si y o Po o [Ins i u o de Saúde Pública
da Uni e sidade do Po o]. Coho s: EPIPo o Po o, Po ugal: ISPUP.
h p://ispup.up.p / esea ch/ esea ch-s uc u es/coho s/?lang=en. Accessed
22 No embe 2015.
13. Alda de Cae ano Ca alho & José Pe ei a Miguel. Inqué i o Nacional de
Saúde 2005/2006. Ins i u o Nacional de Es a ís ica and Ins i u o Nacional de
Saúde D . Rica do Jo ge. 2009.
14. Public Heal h Ins i u e o he Uni e si y o Po o [Ins i u o de Saúde Pública
da Uni e sidade do Po o]. Coho s: Gene a ion XXI Po o, Po ugal: ISPUP.
h p://ispup.up.p / esea ch/ esea ch-s uc u es/coho s/ge acaoxxi/.
Accessed 22 No embe 2015.
15. Public Heal h Ins i u e o he Uni e si y o Po o [Ins i u o de Saúde Pública
da Uni e sidade do Po o]. Coho s: EPITeen Po o, Po ugal: ISPUP.
h p://ispup.up.p / esea ch/ esea ch-s uc u es/coho s/epi een/.
Accessed 22 No embe 2015.
16. Mi anda MJ, Cos a C, San ana P, Ba ozo LV. Associação espacial en e
a iá eis socioeconômicas e isco ela i o de nascimen os p é- e mo na
Região Me opoli ana de São Paulo (RMSP) e na Á ea Me opoli ana de
Lisboa (AML). Saúde Soc. 2014;23(4):1142–53.
17. Ha ding S, Bo ouje di M, San ana P, C uickshank J. Decline in, and lack o
di e ence be ween, a e age bi h weigh s among A ican and Po uguese
babies in Po ugal. In J Epidemiol. 2006;35(2):270–6.
18. Oli ei a C, Economou T, Bailey T, Mendonça D, Pina M. The in e ac ions
be ween municipal socioeconomic s a us and age on hip ac u e isk.
Os eopo os In . 2015;26(2):489–98.
19. on Humbold S, Leal I, Pimen a F. Li ing well in la e li e: he in luence o
sense o cohe ence, and socio-demog aphic, li es yle and heal h- ela ed
ac o s on olde adul s’sa is ac ion wi h li e. Applied Resea ch in Quali y o
Li e. 2014;9(3):631–42.
20. Bas os J, Pele ei o B, Ba os R, Al es L, Se e o M, Fá ima Pina M, e al.
Sociodemog aphic de e minan s o p e alence and incidence o Helicobac e
pylo i in ec ion in Po uguese adul s. Helicobac e . 2013;18(6):413–22.
21. Williamson LM, Rosa o M, Teyhan A, San ana P, Ha ding S. AIDS mo ali y in
A ican mig an s li ing in Po ugal: e idence o la ge social inequali ies.
Sex T ansm In ec . 2009;85(6):427–31.
22. Ha ding S, Teyhan A, Rosa o M, San ana P. All cause and ca dio ascula
mo ali y in A ican mig an s li ing in Po ugal: e idence o la ge social
inequali ies. Eu J Ca dio asc P e Rehabil. 2008;15(6):670–6.
23. Ne o F. P edic o s o men al heal h among adolescen s om immig an
amilies in Po ugal. J Fam Psychol. 2009;23(3):375.
24. Ne o F. Men al heal h among adolescen s om e u ned Po uguese
immig an amilies om No h Ame ica. N Am J Psychol. 2010;12(2):265.
25. San os DA, Sil a AM, San a-Cla a H, Ma ias CN, Fields DA, Sa dinha LB.
De e minan ac o s o ca dio espi a o y i ness in Po uguese adolescen s
o di e en e hnici ies. Re is a B asilei a de Cinean opome ia & Desempenho
Humano. 2011;13(4):243–9.
26. F aga S, Ma ques-Vidal P, Vollenweide P, Waebe G, Guessous I, Paccaud F,
e al. Associa ion o socioeconomic s a us wi h in lamma o y ma ke s: A wo
coho compa ison. P e en i e medicine. 2014.
27. Ha ding S, San ana P, C uickshank JK, Bo ouje di M. Bi h weigh s o black
A ican babies o mig an and nonmig an mo he s compa ed wi h hose o
babies o Eu opean mo he s in Po ugal. Ann Epidemiol. 2006;16(7):572–9.
28. Sil a PA. Indi idual and social de e minan s o sel - a ed heal h and well-
being in he elde ly popula ion o Po ugal. Cade nos de saude publica.
2014;30(11):2387–400.
29. Sousa-Ribei o M, S e ke M, Coimb a JL. Pe cei ed quali y o he psychosocial
en i onmen and well-being in employed and unemployed olde adul s: he
impo ance o la en bene i s and en i onmen al i amins. Econ Ind Democ .
2014;35(4):629–52.
30. Aze edo LF, Cos a-Pe ei a A, Mendonça L, Dias CC, Cas o-Lopes JM.
Epidemiology o ch onic pain: a popula ion-based na ionwide s udy on i s
p e alence, cha ac e is ics and associa ed disabili y in Po ugal. The jou nal
o pain. 2012;13(8):773–83.
31. Al es E, Co eia S, Ba os H, Aze edo A. P e alence o sel - epo ed
ca dio ascula isk ac o s in Po uguese women: a su ey a e deli e y.
In e na ional jou nal o public heal h. 2012;57(5):837–47.
32. Pe elman J, Fe nandes A, Ma eus C. Gende dispa i ies in heal h and
heal hca e: esul s om he Po uguese Na ional Heal h In e iew Su ey.
Cade nos de saude publica. 2012;28(12):2339–48.
33. S ewa -Knox B, Du y ME, Bun ing B, Pa H, de Almeida MDV, Gibney M.
Associa ions be ween obesi y (BMI and wais ci cum e ence) and socio-
demog aphic ac o s, physical ac i i y, die a y habi s, li e e en s, esilience,
mood, pe cei ed s ess and hopelessness in heal hy olde Eu opeans.
BMC Public Heal h. 2012;12(1):424.
34. Ca alho J, Nob e P. Gende issues and sexual desi e: he ole o emo ional
and ela ionship a iables. J Sexual Med. 2010;7(7):2469–78.
35. Cos a C, Ramos E, Se e o M, Ba os H, Lopes C. De e minan s o ea ing
diso de s symp oma ology in Po uguese adolescen s. A chi es o pedia ics
& adolescen medicine. 2008;162(12):1126–32.
36. Lawlo DA, Ha o M, Wedde kopp N, Ande sen LB, Sa dinha LB, Riddoch CJ,
e al. Associa ion o socioeconomic posi ion wi h insulin esis ance among
child en om Denma k, Es onia, and Po ugal: c oss sec ional s udy. BMJ.
2005;331(7510):183.
37. Co eia S, Ba os H. Small- o -ges a ional age Po uguese babies: he e ec
o childhood social en i onmen , g ow h and adul socioeconomic
condi ions. P e Med. 2015;70:102–7.
38. Mello T, An unes I, Waldman E, Ramos E, Rel as M, Ba os H. P e alence and
se e i y o den al ca ies in schoolchild en o Po o, Po ugal. Communi y
Den Heal h. 2008;25(2):119–25.
39. Schü e S, Chas ang J-F, Pa en -Thi ion A, Ve meylen G, Niedhamme I.
Social di e ences in sel - epo ed heal h among men and women in 31
coun ies in Eu ope. Scandina ian jou nal o public heal h. 2013;41(1):51–7.
40. Co eia S, Rod igues T, Ba os H. Socioeconomic a ia ions in emale e ili y
impai men : a s udy in a coho o Po uguese mo he s. BMJ open.
2014;4(1):e003985.
41. Pimen a F, Leal I, Ma oco J, Ramos C. Pe cei ed con ol, li es yle, heal h,
socio-demog aphic ac o s and menopause: Impac on ho lashes and
nigh swea s. Ma u i as. 2011;69(4):338–42.
42. Fe ei a-Valen e MA, Pais-Ribei o JL, Jensen MP. Associa ions be ween
psychosocial ac o s and pain in ensi y, physical unc ioning, and
psychological unc ioning in pa ien s wi h ch onic pain: a c oss-cul u al
compa ison. Clin J Pain. 2014;30(8):713–23.
43. Camões M, Lopes C, Oli ei a A, San os AC, Ba os H. O e all and cen al
obesi y incidence in an u ban Po uguese popula ion. P e Med.
2010;50(1):50–5.
44. San os A-C, Ba os H. P e alence and de e minan s o obesi y in an u ban
sample o Po uguese adul s. Public Heal h. 2003;117(6):430–7.
45. Noguei a H, Fe ão M, Gama A, Mou ão I, Rosado Ma ques V, Padez C.
Pe cep ions o neighbo hood en i onmen s and childhood obesi y:
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 9 o 10
e idence o ha m ul gende inequi ies among Po uguese child en.
Heal h & place. 2013;19:69–73.
46. Bingham DD, Va ela‐Sil a MI, Fe ão MM, Augus a G, Mou ão MI, Noguei a H,
e al. Socio‐demog aphic and beha io al isk ac o s associa ed wi h he high
p e alence o o e weigh and obesi y in po uguese child en. Am J Hum Biol.
2013;25(6):733–42.
47. Dias S, Gama A, Ma ins MO. Heal h s a us and p e en a i e beha io s o
immig an s by gende and o igin: a Po uguese c oss‐sec ional s udy.
Nu sing Heal h Sci. 2013;15(3):309–17.
48. Eikemo TA, Huisman M, Bamb a C, Kuns AE. Heal h inequali ies acco ding
o educa ional le el in di e en wel a e egimes: a compa ison o 23
Eu opean coun ies. Sociology o heal h & illness. 2008;30(4):565–82.
49. Von Dem Knesebeck O, Ve de PE, D agano N. Educa ion and heal h in 22
Eu opean coun ies. Soc Sci Med. 2006;63(5):1344–51.
50. Pe ei a M, Cana a o MC. Gende and age di e ences in quali y o li e and
he impac o psychopa hological symp oms among HIV-in ec ed pa ien s.
AIDS Beha . 2011;15(8):1857–69.
51. Bamb a C, Pope D, Swami V, S anis ee D, Roskam A, Kuns A, e al. Gende ,
heal h inequali ies and wel a e s a e egimes: a c oss-na ional s udy o 13
Eu opean coun ies. J Epidemiol Communi y Heal h. 2009;63(1):38–44.
52. Ribei o O, Teixei a L, A aújo L, A onso RM, Pachana N. P edic o s o anxie y
in cen ena ians: heal h, economic ac o s, and loneliness. In e na ional
Psychoge ia ics. 2014. p. 1–10.
53. Ama al MOP, de Figuei edo Pe ei a CM, Ma ins DIS, Sakella ides CT.
P e alence and isk ac o s o insomnia among Po uguese adolescen s.
Eu J Pedia . 2013;172(10):1305–11.
54. Ca alho M, de Ma os MG. Psychosocial de e minan s o men al heal h and
isk beha iou s in adolescen s. Global J Heal h Sci. 2014;6(4):22.
55. Bulhões C, Ramos E, Linde J, Dias S, Ba os H. Dep essi e symp oms and
i s associa ed ac o s in 13-yea -old u ban adolescen s. In e na ional jou nal
o en i onmen al esea ch and public heal h. 2013;10(10):5026–38.
56. San os NC, Cos a PS, Cunha P, Po ugal-Nunes C, Amo im L, Co e J, e al.
Clinical, physical and li es yle a iables and ela ionship wi h cogni ion and
mood in aging: a c oss-sec ional analysis o dis inc educa ional g oups.
F on ie s in aging neu oscience. 2014. p. 6.
57. Roskam A-JR, Kuns AE, Van Oyen H, Dema es S, Klumbiene J, Regido E,
e al. Compa a i e app aisal o educa ional inequali ies in o e weigh and
obesi y among adul s in 19 Eu opean coun ies. In J Epidemiol.
2010;39(2):392–404.
58. Gal DL, San os A-C, Ba os H. Leisu e- ime e sus ull-day ene gy
expendi u e: a c oss-sec ional s udy o seden a ism in a Po uguese u ban
popula ion. BMC Public Heal h. 2005;5(1):16.
59. Mo ei a PA, Pad ão PD. Educa ional and economic de e minan s o ood
in ake in Po uguese adul s: a c oss-sec ional su ey. BMC Public Heal h.
2004;4(1):58.
60. Oli ei a IT. Fecundidade e educação. Re is a de Es udos Demog á icos.
2007;40:5–19.
61. Da is EM, Zyzanski SJ, Olson CM, S ange KC, Ho wi z RI. Racial, e hnic, and
socioeconomic di e ences in he incidence o obesi y ela ed o childbi h.
Am J Public Heal h. 2009;99(2):294.
62. Kuns AE, Bos V, Lahelma E, Ba ley M, Lissau I, Regido E, e al. T ends in
socioeconomic inequali ies in sel -assessed heal h in 10 Eu opean coun ies.
In J Epidemiol. 2005;34(2):295–305.
63. Huisman M, Van Len he F, Mackenbach J. The p edic i e abili y o sel -
assessed heal h o mo ali y in di e en educa ional g oups. In J
Epidemiol. 2007;36(6):1207–13.
64. Oksuzyan A, Juel K, Vaupel JW, Ch is ensen K. Men: good heal h and high
mo ali y. Sex di e ences in heal h and aging. Aging Clin Exp Res.
2008;20(2):91–102.
65. McDonough P, Wal e s V. Gende and heal h: eassessing pa e ns and
explana ions. Soc Sci Med. 2001;52(4):547–59.
66. Macin y e S, Hun K, Swee ing H. Gende di e ences in heal h: a e hings
eally as simple as hey seem? Soc Sci Med. 1996;42(4):617–24.
67. Rieke PP, Bi d CE. Re hinking gende di e ences in heal h: why we need
o in eg a e social and biological pe spec i es. J Ge on ol Se B Psychol
Sci Soc Sci. 2005;60(Special Issue 2):S40–S7.
68. Eu os a . Mig an s in Eu ope. Belgium: A s a is ical po ai o he i s and
second gene a ion; 2011.
69. Eu opean Commission. People a isk o po e y o social exclusion.
h p://ec.eu opa.eu/eu os a /s a is ics-explained/index.php/People_a _ isk_
o _po e y_o _social_exclusion. Accessed 22 No embe 2015.
70. Kawachi I, Sub amanian S, Almeida-Filho N. A glossa y o heal h
inequali ies. J Epidemiol Communi y Heal h. 2002;56(9):647–52.
71. Eu os a . Old-age dependency a io pe 100 pe sons. h p://ec.eu opa.eu/
eu os a / gm/ able.
do? ab= able&ini =1&language=en&pcode= sdde510&plugin=1. Accessed 3
Feb 2015.
72. Di eção-Ge al da Saúde. A Saúde dos Po ugueses. Pe spe i a 2015 Lisbon:
Di eção-Ge al da Saúde. 2015.
73. Ma mo M. Heal h inequali ies in he EU. Final epo o a conso ium.
Heal h inequali ies in he EU Final epo o a conso ium. 2013.
74. Di ecção-Ge al da Saúde. Plano Nacional de Saúde: Re isão e Ex ensão a
2020. Lisbon: Di ecção-Ge al da Saúde; 2015.
75. Smi h KE, El anani MK. Wha kinds o policies o educe heal h inequali ies
in he UK do esea che s suppo ? Jou nal o Public Heal h. 2015;37(1):6–17.
76. B a eman P, G uskin S. De ining equi y in heal h. J Epidemiol Communi y
Heal h. 2003;57(4):254–8.
• We accep p e-submission inqui ies
• Ou selec o ool helps you o ind he mos ele an jou nal
• We p o ide ound he clock cus ome suppo
• Con enien online submission
• Tho ough pee e iew
• Inclusion in PubMed and all majo indexing se ices
• Maximum isibili y o you esea ch
Submi you manusc ip a
www.biomedcen al.com/submi
Submi you nex manusc ip o BioMed Cen al
and we will help you a e e y s ep:
Campos-Ma os e al. In e na ional Jou nal o Equi y in Heal h (2016) 15:26 Page 10 o 10
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
95
2.4. Shi ing de e minan s o heal h inequali ies in uns able imes:
Po ugal as a case s udy
Re e ence:
Campos-Ma os I, Russo G, Gonçal es L. Shi ing de e minan s o heal h inequali ies
in uns able imes: Po ugal as a case s udy. Accep ed o publica ion in he Eu opean
Jou nal o Public Heal h in May 2017. DOI:
h ps://dx.doi.o g/10.1093/eu pub/ckx080
Online supplemen a y da a o his publica ion is in Appendix 4.
The ela ionship be ween con ex and heal h inequali ies Chap e 2. Resul s
96
Eu opean Jou nal o Public Heal h, 1–6
ßThe Au ho 2017. Published by Ox o d Uni e si y P ess on behal o he Eu opean Public Heal h Associa ion. All igh s ese ed.
doi:10.1093/eu pub/ckx080
.........................................................................................................
Shi ing de e minan s o heal h inequali ies in uns able
imes: Po ugal as a case s udy
Ine
ˆs Campos-Ma os
1,2
, Giuliano Russo
3
, Luzia Gonc¸al es
1,4
1 Ins i u o de Higiene e Medicina T opical, No a Uni e si y o Lisbon, Lisbon, Po ugal
2 Cen o de In es igac¸a
˜o em Sau
´de Pu
´blica, Lisbon, Po ugal
3 Depa men o P ima y Ca e and Public Heal h, Queen Ma y Uni e si y o London, London, UK
4 Cen o de Es a ı
´s ica e Aplicac¸o
˜es da Uni e sidade de Lisboa, Lisbon, Po ugal
Co espondence: Ine
ˆs Campos-Ma os, Depa amen o de Sau
´de In e nacional e Bioes a ı
´s ica, Ins i u o de Higiene e
Medicina T opical, Rua da Junquei a, n100, 1349-008 Lisboa, Po ugal, Tel: +44 750 282 3003,
e-mail: [email p o ec ed]
Backg ound: We explo e how heal h inequali ies (HI) changed in Po ugal o e he las decade, conside ing i is
one o he mos unequal Eu opean coun ies and has gone h ough majo economic changes. We desc ibe how
inequali ies in limi a ions changed conside ing di e en socioeconomic de e minan s, in o de o unde s and
wha d o e changes in HI. Me hods: We used c oss-sec ional wa es om he Eu opean Su ey on Income and
Li ing Condi ions da abase o de e mine how inequali ies in heal h limi a ions changed be ween 2004 and 2014 in
Po ugal in esiden s aged 16 yea s and o e . We calcula ed p e alence es ima es o limi a ions and di e ences
be ween income e ciles, he concen a ion index o each yea and i s decomposi ion and mul iple logis ic e-
g essions o es ima e he associa ion be ween socioeconomic de e minan s and limi a ions. Resul s: The
p e alence o heal h limi a ions inc eased in Po ugal since 2004, especially a e 2010, om 35 o 47%. Bu
he di e ence be ween op and bo om income e ciles dec eased om 23 o 10 pe cen age poin s, as iche
people expe ienced a s eepe inc ease. This was d i en by an inc ease in p e alence among economically ac i e
people, who, om 2011 onwa ds, had mo e limi a ions (OR and 95% CI we e 2.42 [2.13–2.75] in 2004 and 0.71
[0.65–0.78] in 2014). Conclusion: These esul s sugges wo sening heal h in Po ugal in he las decade, possibly
connec ed o pe iods o economic ins abili y. Howe e , absolu e HI dec eased conside ably in he same pe iod. We
discuss he possible ole o di e se adap a ion capaci y o socioeconomic g oups, and o high emig a ion a es o
young, heal hie people, e lec ing ano he side o he ‘mig an heal h e ec ’.
.........................................................................................................
In oduc ion
Socioeconomic heal h inequali ies (HI) a e ubiqui ous. They ha e
been obse ed wo ldwide as long as da a ha e been a ailable. I
appea s ha , ega dless o place and ime, heal h ends o ollow he
pa e ning o socioeconomic di e ences (1).
Va ious socioeconomic indica o s—educa ion, inancial
esou ces, employmen o occupa ion—de e mine HI, ope a ing
h ough di e en pa hways. Educa ion leads o be e in o ma ion,
cogni i e abili ies and de e mines p e e ences (2); inancial
esou ces, such as income o weal h, allow indi iduals o access
heal h-p oducing esou ces, such as heal hca e o housing.
Employmen no only p o ides income, bu also a sense o con ol
o e one’s li e, lack o which is s ongly associa ed wi h impo an
s ess eac ions, which can de e io a e heal h (3). People wi h highe
occupa ional g ades also end o ha e a s onge sense o con ol
o e hei heal h, hei jobs and hei li es (4), bu occupa ion can
also e lec an indi idual’s place in socie y, showing he e ec o ank
and subjec i e eelings owa ds one’s posi ion in socie y (2). The
simul aneous analysis o a ious socioeconomic de e minan s o
HI can p o ide clues as o which p ocesses a e mo e impo an in
he c ea ion o HI (5). A be e unde s anding o which p ocesses
shape HI will help o build a base o design policies ha ackle hem
e ec i ely.
Po ugal is a pa icula ly in e es ing case s udy o HI. The
coun y has had low economic g ow h (6), and despi e subs an ial
in es men s in social p o ec ion, educa ion and heal hca e (7,8),
emains one o he mos unequal Eu opean Union coun ies in
income dis ibu ion (9). This is e lec ed in heal h dis ibu ion:
se e al analyses ound Po ugal o ha e some o he highes HI
among Eu opean coun ies (10–12). Addi ionally, Po ugal has
gone h ough a pe iod o economic c isis and implemen a ion o
aus e i y measu es in he las yea s, ha ha e led o a spike in
emig a ion (13) and a de e io a ion o public social se ices (14).
A ecen e iew o he impac o economic c ises ound ha hey
ended o agg a a e HI in a a ie y o coun ies (15). Howe e , he
e iew no ed ha esul s we e a iable, pe haps due o di e ing
wel a e policies, o he di e si y o heal h and socioeconomic
a iables. Poo unde s anding o how economic c ises shape HI
hinde s he in e p e a ion o hese esul s.
This wo k aims o suppo policy choices ha a emp o mi iga e
he e ec o economic c ises o o he con ex ual changes on HI. To
do his, we desc ibe how HI changed in Po ugal o e he las
decade, in ligh o he impo an social and mac oeconomic
changes ha he coun y has been h ough, and how he
socioeconomic de e minan s o hese inequali ies changed. We
used da a om he c oss-sec ional wa es o he Eu opean Su ey
on Income and Li ing Condi ions (EU-SILC), om 2004 o 2014.
Po ugal is used as a case s udy, bu his analysis is applicable o
o he coun ies as i desc ibes how de e minan s o HI can be shaped
by con ex ual ans o ma ions. This is pa icula ly use ul conside ing
ha many coun ies ha e ecen ly gone h ough simila mac oeco-
nomic changes as Po ugal.
Me hods
This analysis was pe o med using da a om he Po uguese c oss-
sec ional wa es o EU-SILC be ween 2004 and 2014 (p o ided by
Eu os a in Decembe 2015). EU-SILC is an annual su ey ca ied
ou in se e al Eu opean coun ies wi h a mixed longi udinal and
c oss-sec ional design. Despi e his mixed design, c oss-sec ional
samples a e ep esen a i e o he a ge popula ion when app op ia e
weigh s a e used (16). Po ugal pa icipa es since 2004 using a
s a i ied, mul i-s age, household-based sample. The su ey collec s
da a on li ing condi ions and includes h ee heal h ela ed ques ions:
limi a ions in daily ac i i ies due o heal h p oblems, sel - epo ed
heal h (SRH) and ch onic condi ions.
We used ‘limi a ions’ as ou heal h ou come. Indi iduals we e
asked i hey we e limi ed in ac i i ies hey usually did because o
heal h p oblems. Possible answe s included ‘Yes, s ongly limi ed’,
‘Yes, limi ed’ o ‘No’. The i s wo op ions we e collapsed, c ea ing a
bina y a iable (1 = ‘wi h limi a ions’, 0 = ‘wi hou limi a ions’).
This heal h ou come was chosen as i p o ides an objec i e
measu e han SRH and should cap u e heal h s a us mo e
accu a ely (17). The ini ial desc ip i e analysis was also done o
he o he wo heal h a iables: SRH and ch onic condi ions. SRH
is a widely used su ey measu e in which esponden s a e hei
o e all heal h; we used SRH as a bina y a iable in which ‘bad’
and ‘ e y ba ’ heal h we e he ou come. ‘Ch onic condi ions’ is a
sel -assessed ques ion in which esponden s a e asked whe he hey
ha e a ch onic condi ion; his was also used as a bina y a iable, in
which ha ing a ch onic condi ion was he ou come.
The ollowing a iables we e included in he analysis:
Age a in e iew (in yea s).
Sex (male o emale).
Income: yea ly household equi alised disposable income, in
eu os, de la ed using he ha monised index o consume p ices
(18).
Educa ion: de ined by highes In e na ional S anda d
Classi ica ion o Educa ion (ISCED) le el a ained (19),
ca ego ised in o ‘p ima y o less’ o ‘mo e han p ima y’.
Occupa ion: based on he In e na ional S anda d Classi ica ion
o Occupa ions (ISCO) used in EU-SILC, occupa ions we e
ca ego ised in whi e o blue colla , ollowing p e ious wo k
(ISCO codes 1–5 we e whi e colla , 6–9 blue colla and a med
o ces we e excluded) (20).
Ac i i y: based on he EU-SILC a iable ‘sel -de ined cu en
economic s a us’, people we e ca ego ised as ‘ac i e’ i hey
de ined hemsel es as being employed (pa o ull ime), in
aining o s udying, o ul illing domes ic asks; and ‘inac i e’
i hey we e unemployed, e i ed, un i o wo k o in he ‘o he
inac i e’ ca ego y.
Sa ings: EU-SILC u he asks households abou hei capaci y o
ace unexpec ed inancial expenses and o a o d one-week
annual holiday away om home. These wo a iables we e
me ged and ans o med in o a bina y a iable so ha he
alue ‘0’ was a ibu ed o households who could a o d bo h
and ‘1’ o he emaining households.
We used he comple e sample o esiden s aged 16 and o e . The
p opo ion o indi iduals who had limi a ions was calcula ed o
each yea in he o e all sample, wi hin each income e cile, and
s a i ied by age g oups. Income e ciles we e calcula ed acco ding
o he dis ibu ion o income o each yea .
The concen a ion index (CIx) o income- ela ed inequali ies in
limi a ions was calcula ed o each yea . The CIx is a measu e o
inequali ies based on he heal h concen a ion cu e. This cu e is
he esul o plo ing o he cumula i e pe cen age o indi iduals,
anked by income, wi h he cumula i e pe cen age o limi a ions. In
his plo , pe ec equali y is ep esen ed by a diagonal line, showing
an equal dis ibu ion o limi a ions among he popula ion,
ega dless o income. The CIx is calcula ed as wice he a ea
be ween he concen a ion cu e and he line o pe ec equali y.
When he e is pe ec equali y, he CIx is ze o. By con en ion, i
all limi a ions a e concen a ed in he iches (poo es ) pe son, he
CIx is 1 (-1). Howe e , wi h dicho omous ou come a iables, he
CIx is no wi hin he [-1,1] ange and be ween-yea compa abili y
may be limi ed; ollowing Wags a (21), o minimise his limi a ion,
we no malised he CIx by di iding i by 1 minus he p opo ion o
esponden s epo ing limi a ions in each yea .
Wags a e al. (22) showed ha he CIx can be decomposed in o
con ibu ions o indi idual ac o s o he income- ela ed HI. This
analysis allows o he quan i ica ion o how each ac o (i.e. each
socioeconomic a iable) con ibu es o he o e all dis ibu ion o
he heal h ou come among income anks. The con ibu ion o
each ac o is he p oduc o he elas ici y o ha ac o wi h
espec o he heal h a iable (i.e. he p opo ional change o a
speci ic ac o in ela ion o a p opo ional change in he heal h
a iable) and he CIx o ha ac o (i.e. he deg ee o income-
ela ed inequali y o ha ac o ).
Finally, we pe o med a mul iple logis ic eg ession o each yea ,
using he dicho omous heal h a iable (limi a ions) as an ou come.
We included all he demog aphic and socioeconomic a iables lis ed
abo e as explana o y a iables: age, sex, income, educa ion,
occupa ion, ac i i y and sa ings. These we e all added o he
model simul aneously.
Analyses we e weighed by a pe sonal c oss-sec ional weigh
p o ided by he EU-SILC da abase, which con ols o geog aphical,
household size, gende , and age g oup dis ibu ion, and non-
esponse wi hin each household. Analyses we e done on SPSS
S a is ics 21 and in ADePT So wa e 6.0 using a non-linea
model o he CIx.
Resul s
Table 1 summa ises he sample cha ac e is ics. Yea ly sample size
anged om 9947 indi iduals in 2007 o 14 650 in 2014. A e age age
inc eased om 46.3 o 49.0-yea s-old om 2004 o 2014. The
p opo ion o indi iduals wi h limi a ions also inc eased om 35.2
o 47.3%. Median income inc eased be ween 2004 and 2012, om
5869 o 8366 eu os pe yea , and d opped o 8265 eu os in 2014.
The e was also an inc ease in he p opo ion o people wi h
seconda y and e ia y educa ion and in whi e-colla occupa ions,
bo h ep esen ing app oxima ely hal he sample in 2014. The
p opo ion o ac i e people dec eased om 70% in 2004 o 58.5%
in 2014.
Figu e 1 shows he p opo ion o indi iduals wi h limi a ions by
yea . This p opo ion was s able a a ound 30% un il 2011, when i
inc eased o 43%, and hen inc eased again in 2014 o 47%. These
changes occu ed in all income e ciles, bu a ew di e ences we e
no iceable: (i) in almos e e y yea , he p opo ion o people wi h
limi a ions was highe in he i s e cile ( he lowes -income
popula ion g oup), ollowed by he second, and lowes in he
hi d; (ii) his di e ence was s able un il 2011, when he
p opo ion o limi a ions inc eased in all e ciles, mos ma kedly
in he second and hi d; (iii) his led o a dec ease in he absolu e
di e ence in limi a ions inequali ies be ween he i s and hi d
income e ciles. Figu e 1 poin s ou he absolu e di e ences
be ween he i s and hi d income e ciles in ou yea s (23% age
poin s in 2004 and 2010, 16 in 2011, and 10 in 2014). When
s a i ied by age g oups, he analysis p esen ed in igu e 1 shows
ha inequali ies in limi a ions we e highes in he olde age
g oups, he inc ease in limi a ions in 2011 occu ed in younge
age g oups, and he oldes age g oups showed a dec ease in limi a-
ions in 2012 (Supplemen a y igu e S1A).
The CIx was nega i e e e y yea , as he p e alence o limi a ions
was highe in poo e people ( igu e 2). The CIx anged be ween 0.15
and 0.18 (in absolu e alues) un il 2010 and d opped in 2011 o 0.09
and o 0.05 in 2014. Un il 2010, e e y socioeconomic a iable had a
nega i e con ibu ion o he CIx, meaning ha hey all con ibu ed
o p o-poo inequali y in he dis ibu ion o limi a ions. Howe e ,
a e 2010 he e we e a ew no iceable changes.
Fi s , ac i i y now ga e a posi i e con ibu ion o he CIx.
De ailed analysis o he con ibu ion o each a iable
(Supplemen a y able S1A) showed ha he elas ici y o limi a ions
wi h espec o ac i i y changed in 2011, om posi i e o a nega i e
con ibu ion; he CIx o ac i i y, on he o he hand, emained s able.
This means ha , in all yea s, inac i e people had lowe incomes
when compa ed wi h ac i e people. Howe e , while limi a ions
we e mo e p e alen in inac i e people un il 2010, hey we e mo e
p e alen in ac i e people a e his yea .
2o 6 Eu opean Jou nal o Public Heal h
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
105
We used da a om six ounds o he ESS, be ween 2002 and 2012, which included 36
coun ies and 237,535 indi iduals. Da a was o ganized in h ee le els – indi iduals,
yea s and coun ies – and analysed using mul ile el s a is ical echniques. Coun ies
we e g ouped acco ding o hei wel a e egime ype and analyses we e done
sepa a ely o each g oup. Each indi idual was a ibu ed one o h ee social mobili y
pa hs: upwa d, s able, o downwa d, acco ding o he di e ences be ween hei own
and hei mo he and a he ’s educa ional achie emen (analyses we e done sepa a ely
o mo he and a he ). Heal h was ope a ionalized as a bina y a iable: 1 o ‘bad’ o
‘ e y bad’ SAH and 0 o ‘ ai ’, ‘good’, and ‘ e y good’. In o de o ensu e ha he
social mo emen i sel was analysed and he e ec s o childhood ci cums ances we e
excluded, analyses we e con olled o pa en al educa ion. We calcula ed ela i e
(OR) and absolu e ( isk di e ence) measu es o he associa ion be ween social
mobili y and SAH o each wel a e egime ype.
Resul s showed ha upwa d mobili y (when compa ed o being socially ‘s able’) was
posi i ely associa ed wi h be e heal h in all wel a e egime ypes, measu ed bo h
om mo he and a he ’s achie emen , using absolu e and ela i e measu es. On a
ela i e scale, hese esul s we e s a is ically signi ican o p<0.05. On an absolu e
scale, o me USSR coun ies showed he bigges and only signi ican di e ence o
upwa d mo emen (4.1 and 3.8% di e ence, when social mobili y was measu ed
om he mo he ’s o he a he ’s achie emen , espec i ely). Scandina ian coun ies
showed he smalles and no signi ican di e ences: 0.8 and 0.9% di e ence, om
mo he o a he ’s, espec i ely.
O e all, his analysis showed ha social mobili y was associa ed wi h di e ences in
heal h in all wel a e egime ypes, bu Scandina ian coun ies showed he smalles
associa ion. Despi e ha ing high le els o social mobili y, hese coun ies seemed o
e icien ly sepa a e i om heal h, mo e so han coun ies om o he wel a e egime
ypes. These esul s sugges ha he ‘pa adox’ o high HI in no he n Eu opean
coun ies is unlikely o be due o social mobili y di e ences among wel a e egime
ypes. This analysis did no es o he hypo heses on why HI emain high in no he n
Eu opean coun ies, bu showed ha wel a e egimes play a ole in de e mining bo h
le els o popula ion heal h and heal h dis ibu ion in Eu opean coun ies.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
106
3.1.3. Social De e minan s o Heal h in Po ugal
As one o he mos unequal coun ies in Eu ope, bo h in e ms o income dis ibu ion
(13) and heal h dis ibu ion (14), Po ugal p esen s an in e es ing case s udy o
unde s anding HI. Despi e he high le els o inequali y, WHO iden i ied HI as an
‘impo an policy gap’ in he Po uguese Na ional Heal h Plan (15), which e lec s he
low poli ical in e es in he subjec and he absence o a na ional s a egy in place o
ackle hese inequali ies. I was hus impo an o sys ema ize cu en knowledge on
socioeconomic HI in Po ugal, o se a s epping-s one owa ds a possible s a egy o
ackle HI in he coun y. Fo his, we ca ied ou a SR o he li e a u e ha ga he ed
he exis ing e idence abou socioeconomic HI in Po ugal.
The PRISMA s a emen was used o guide and epo he e iew (16). The e iew
began by de ining wha measu es o SES would be included. Fo his, he
PROGRESS2 amewo k was ollowed, s anding o Place o esidence, Race /
e hnici y / cul u e / language, Occupa ion, Gende /sex, Religion, Educa ion,
Socioeconomic s a us and Social capi al (17). Bo h indi idual and con ex ual
de e minan s we e included. Heal hca e u iliza ion o access, and heal h ela ed
beha iou s we e excluded om he analysis, as we we e in e es ed solely on
inequali ies in heal h ou comes. We included e e y s udy ha quan i ied an
associa ion be ween he socioeconomic and heal h a iables, and con olled o , a
leas , gende and age. S udies ha used da a om 2000 onwa ds and om he
Po uguese esiden popula ion ( ega dless o na ionali y) we e included. We
excluded quali a i e s udies. A icles w i en in Po uguese and English we e
included. We sea ched Scopus, Web o Science and Pubmed o pape s ha me he
eligibili y c i e ia. Addi ionally, we scoped publica ions o esea che s in Po ugal
who egula ly publish esea ch in his a ea o publica ions ha me he eligibili y
c i e ia, o complemen ou online sea ch. Da a was ex ac ed om he selec ed
a icles and a b ie quali y e alua ion was pe o med. Resul s we e p esen ed using a
na a i e desc ip ion and a diag am ha summa ized he indings.
The inal selec ion included se en y-one pape s, all o which epo ed obse a ional
s udies, and mos o which used c oss-sec ional da a. Mos publica ions epo ed
2 The PROGRESS amewo k was c ea ed as an aide-memoi o help esea che s apply an equi y lens
o hei esea ch, and public heal h p o essionals o conside all po en ially inequi able ci cums ances in
public heal h in e en ions.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
107
signi ican HI ha a ou ed indi iduals o g oups wi h be e social s anding. Some
associa ions we e pa icula ly common and showed s ong e idence o HI: lowe
educa ion wi h obesi y and wi h subjec i e ill heal h; and emale gende wi h men al
heal h symp oms and subjec i e ill heal h.
O he se en y-one selec ed pape s in he SR, se en een analysed, in one way o
ano he , he e ec o a con ex ual a iable. Se en o hese s udies had an ecological
design (18-24). Fou in es iga ed how an indi idual’s pe cep ions o hei
neighbou hood we e associa ed o hei heal h (25-28). Fou o he s udies explo ed
he di e ence be ween esiden s o u ban and u al se ings (29-32). The wo
emaining s udies looked a di e ences be ween dep i ed and a luen
neighbou hoods (33) and municipali ies (34). O e all, hese we e e y he e ogeneous
s udies, looking a di e en opics, di e en popula ions, and wi h di e ing deg ees
o quali y.
This e iew o e ed a sys ema iza ion o cu en e idence on HI in Po ugal, which
had no been done be o e. I s esul s show ha , while he e a e a conside able numbe
o publica ions ouching on he subjec , hey end o ocus on speci ic opics,
ep oducing simila esul s; hey do no necessa ily ocus on wha a e he mos
p e alen heal h and social issues in Po ugal; and hey end o use simila
me hodologies. This analysis was also able o iden i y wha a e he mos impo an HI
in Po ugal o which e idence is a ailable – educa ion and gende inequali ies in
obesi y, SAH and men al heal h – and he majo gaps in he esea ch li e a u e
ega ding his opic – analyses ocused on he mos p e alen heal h issues, he mos
impo an SES ac o s, and he mos ulne able popula ions. I is clea om hese
esul s ha , a he p esen momen , he e is no na ionally o ien ed esea ch s a egy
which would be c ucial o guide esea ch in a coun y whe e HI emain pa icula ly
high.
3.1.4. Shi ing De e minan s o Heal h Inequali ies in Po ugal
Many indi idual socioeconomic a iables can de e mine HI. Educa ion, one o he
mos commonly used indica o s, can de e mine be e cogni i e abili ies and be e
knowledge, ha allow indi iduals o p e en illness, ha e be e heal h, and be e
manage disease (35). Financial esou ces can allow indi iduals o acqui e heal h-
p oducing esou ces (36). Employmen p o ides income, bu also a sense o pu pose,
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
108
a s uc u e o he day, and social connec ions, which a e all associa ed wi h be e
heal h (37). Occupa ion, on he o he hand, is a e lec ion o social ank, and has also
been s ongly connec ed o mul iple heal h ou comes; amously, he Whi ehall s udies
showed ha hese di e ences we e a consequence o eelings o con ol o e one’s
li e, which a e s onge among people in highe occupa ional anks (38). This a ie y
o SES indica o s is a e lec ion o he mul i ude o pa hways ha lead o HI.
Obse ing which indica o s a e mo e impo an , and how hese change o e ime, can
gi e impo an clues o which p ocesses a e he mos ele an in c ea ing HI. Po ugal
has been h ough impo an changes o e he las decade, wi h pe iods o poli ical
ins abili y and implemen a ion o aus e i y measu es (39). These ans o ma ions
p o ide a unique oppo uni y o obse e how con ex ual changes can lead o changes
in o e all heal h, heal h dis ibu ion, and o he de e minan s o HI. Wi h he ou h
publica ion, we aimed o desc ibe how he de e minan s o HI changed in Po ugal
o e he las decade, in o de o unde s and wha p ocesses c ea ed HI and how hese
changed o e ime. This unde s anding can hope ully lead o in o med policies ha
can success ully ackle HI.
The ou h and las publica ion o his disse a ion used da a om he c oss-sec ional
wa es o he Po uguese sample o EU-SILC om 2004 o 2014 was used, wi h
limi a ions in daily ac i i ies as he ou come a iable. We calcula ed he p e alence o
limi a ions in each income e cile in each yea and absolu e di e ences be ween i s
and hi d e ciles o selec ed yea s. We hen calcula ed he CIx o each yea and i s
decomposi ion in a ious SES indica o s: occupa ion, employmen , educa ion,
income, sa ings, age, and sex. Finally, we an a mul iple logis ic eg ession analysis
o each yea , o de e mine he OR o each o hese indica o s.
The p e alence o limi a ions was ound o ha e inc eased in Po ugal in he las
decade, especially a e 2010. Howe e , his inc ease was s eepe in iche e ciles,
which led o a dec ease in bo h absolu e and ela i e inequali ies in limi a ions.
Analysis o he CIx decomposi ion and o he OR showed ha p o essional ac i i y
was he main de e minan o he dec ease in inequali y – ac i e people had ewe
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
109
limi a ions han inac i e people be o e 2011, bu his pa e n e e sed om his yea ,
as ac i e people had mo e limi a ions3.
This analysis was he i s ha looked a he change o HI in Po ugal o e ime.
Despi e ocusing on one coun y alone, se e al lessons can be applied o o he
con ex s o esea ch and policy pu poses. Fi s ly, HI changed conside ably in
Po ugal o e he las decade, possibly ela ed o changes in he coun y’s social and
economic ci cums ances. In 2011 Po ugal wen h ough a pe iod o conside able
unce ain y wi h he eques o a €78 billion bailou om he EU and he In e na ional
Mone a y Fund, esigna ion o he uling go e nmen and snap elec ions, and cons an
alks o aus e i y measu es ha would o ce he Po uguese o ‘ igh en hei bel ’ in
he nea u u e (40). This migh ha e in luenced o e all heal h and changes in i s
dis ibu ion, which highligh s he impo ance o con ex ual de e minan s on HI and
adds knowledge o he g owing body o e idence o he impac o economic c ises on
HI (41). Secondly, i shows ha HI, e en wi hin one coun y, a e nei he s a ic no
de e mined by he same ac o s o e ime. On he con a y, con ex ual socioeconomic
changes can ha e subs an ial impac s on HI and on wha d i es hem. Finally, his
unde s anding o he d i e s o HI can be ex emely use ul o ou line policies o ackle
hem. In ou analysis, he main d i e o dec easing HI was an in e sion in he
p e alence o limi a ions among ac i e and inac i e people. We hypo hesized his
may be a consequence o high emig a ion a es in he coun y (which led o an exi o
heal hie , iche people) o o di e en adap a ion capaci y among socioeconomic
g oups (as g oups o highe social s anding may be less capable o adap ing o wo se
socioeconomic ci cums ances).
3.1.5. Summa y
These ou publica ions pain a pic u e o how con ex ual de e minan s in e ac wi h
indi idual cha ac e is ics o in luence he dis ibu ion o heal h in Po ugal and in i s
wide Eu opean con ex . The analyses and hei esul s a e summa ized in able 2.
Con ex ual social capi al was ound o ha e no impac on popula ion heal h in
Eu opean coun ies, bu had an e ec o a pa icula g oup o people – hose wi h
low indi idual le els o in e pe sonal us . Wel a e egime ypes we e also associa ed
3 People we e conside ed ‘ac i e’ i hey we e employed (pa o ull ime), in aining o s udying, o
ul illing domes ic asks; ‘inac i e’ people we e unemployed, e i ed, un i o wo k o in he ‘o he
inac i e’ ca ego y.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
110
wi h he magni ude o he heal h impac o social mobili y, wi h Scandina ian
coun ies showing he smalles absolu e di e ences. Finally, impo an con ex ual
changes in Po ugal o e he las decade seem o ha e in luenced heal h and i s
dis ibu ion in he coun y.
F om a di e en pe spec i e, he SR sough o summa ize he knowledge on HI in
Po ugal up o da e. This analysis showed ha he s udy o con ex ual de e minan s o
HI is s ill uncommon in Po ugal and ocused on a limi ed numbe o de e minan s.
Resul s o his pape mus be in e p e ed wi h cau ion as hey agg ega e all he da a on
HI in Po ugal o e he las decade; as he ou h publica ion showed, his was a ime
o in ense changes in he dis ibu ion o heal h in Po ugal, so agg ega ing he esul s
o e his pe iod o ime may ha e hidden impo an in o ma ion.
Table 2. Summa y o disse a ion publica ions, de e minan s es ed, geog aphic con ex , ime pe iod,
and main indings.
Publica ion
Social Capi al and
Heal h in Eu opean
Coun ies
Social Mobili y and
Heal h in Eu opean
Wel a e Regimes
Social
De e minan s o
Heal h in Po ugal
Shi ing
De e minan s o
Heal h Inequali ies
in Po ugal
Con ex ual
de e minan
Social capi al
Wel a e egime
n/a
Mac oeconomic
con ex
Indi idual
de e minan
Social capi al
Social mobili y
n/a
Socioeconomic
de e minan s (a)
Con ex
Eu ope
Eu ope
Po ugal
Po ugal
Time pe iod
2002-2012
2002-2012
2000-2014
2004-2014
Main
indings
Impo an c oss-
sec ional
in e ac ion – low
us indi iduals
ha e wo se heal h
in high us
con ex s
Scandina ian
coun ies had he
smalles associa ion
be ween social
mobili y and heal h
Few s udies on
con ex ual
de e minan s o
heal h.
HI dec eased in
Po ugal a e 2010,
mos ly due o
wo se heal h
among
p o essionally
ac i e people
(a) Fi e indi idual de e minan s we e es ed: occupa ion, ac i i y, income, educa ion, and sa ings.
HI: Heal h Inequali ies
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
111
3.2. Limi a ions
The publica ions included in his analysis a e subjec o a numbe o limi a ions.
Limi a ions ha a e speci ic o each publica ion ha e been spelled ou in he esul s
sec ion. Some limi a ions a e common o wo o mo e publica ions.
The i s is ha he da a ha ha was used was c oss-sec ional. EU-SILC has a
longi udinal componen ha could ha e been used, bu panels only las ou yea s, and
his was no conside ed a su icien amoun o ime o assess changes in heal h
ou comes. As such, i was decided o use only c oss-sec ional da a. This decision
limi ed he s udy’s abili y o de e mine whe he heal h is an ou come o he
de e minan unde s udy, o he o he way a ound. Howe e , i was ied, when
app op ia e, o conside bo h di ec ions o he associa ion. Fo example, by
acknowledging bo h p ocesses o heal h selec ion and o he impac o social mobili y
in heal h in he second publica ion.
Ano he possible sou ce o limi a ions is om he used heal h a iables. The use o
SAH and o heal h limi a ions is open o c i icism, bu i mus also be conside ed ha
hese ha e impo an alue, and he e is a eason why mos popula ion su eys ask
hese ques ions speci ically. SAH has been shown o be a eliable measu e o o e all
heal h (42), and e en a good p edic o o mo ali y (43). A guably, SAH is a be e
measu e o heal h han an ‘objec i e’ one, such as a diagnosed illness, as i
inco po a es he indi idual’s pe cep ion o hei own heal h (42). Sel - epo ed
limi a ions in daily ac i i ies a e also a e lec ion o he indi idual’s pe cep ions, bu
p o ide a mo e objec i e measu e han SAH. This ou come has been used by o he
au ho s as an objec i e measu e o unc ional limi a ions (44, 45) and Eu os a uses i
as measu e o disabili y (46).
The wo i s publica ions mus also be in e p e ed wi h cau ion as hey consis o
c oss-coun y compa isons o subjec i e measu es, which may be in e p e ed
di e en ly in each coun y. This is pa icula ly impo an o he i s publica ion, as
in e pe sonal us showed conside able a ia ion be ween coun ies. We ied o
add ess his issue by using coun ies as ixed e ec s, hus emo ing om he model
ime-in a ian coun y cha ac e is ics.
As a whole, he ou publica ions may also occasionally seem o bea only a loose
connec ion, as hey ocus on di e en geog aphical a eas, on di e en de e minan s o
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
112
heal h, and a e some imes amed in ways ha do no seem o be connec ed. Indeed,
he SR o he li e a u e was sligh ly di e en in i s goals, bu was conside ed a
necessa y i s s ep, in o de o agg ega e all a ailable knowledge abou HI in
Po ugal be o e ca ying on u he esea ch. Excluding he SR, all he publica ions
look a con ex ual cha ac e is ics – be i wel a e egime, social capi al, o an economic
c isis – and how hese ha e an impac on he dis ibu ion o heal h wi hin pa icula
popula ion g oups.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
113
3.3. The E ec o Con ex on Heal h and on Heal h Dis ibu ion
As was ou lined in he in oduc ion, he s udy o con ex and how i in luences heal h
and HI has been unde mined by a lack o a heo e ical basis on how con ex ual
de e minan s wo k. Bo h he CSDH and Dide ichsen ha e ecognised he ole o
con ex in c ea ing HI, bu only inso a as i is esponsible o social s a i ica ion and
o he p oduc ion o policies (47, 48). While help ul o policy o mula ion, his is an
incomple e iew o how con ex can in luence heal h and HI.
The amewo k p oposed he e seeks o ill his gap by ou lining he mechanisms by
which con ex in luences heal h and heal h dis ibu ion. I does his by desc ibing wo
mechanisms: (i) changes in o e all hea h and (ii) changes in heal h dis ibu ion. This
dis inc ion is impo an because, jus as is a gued o he CSDH’s amewo k (48),
policies aimed a imp o ing popula ion heal h do no always ha e a posi i e impac
on i s dis ibu ion. Hence, when seeking o in luence HI, i is no enough o
implemen a policy o imp o e o e all heal h. Ra he , i is impo an o conside how
ha policy can change heal h dis ibu ion also. I is hoped ha he amewo k
p oposed he e con ibu es o he absence o his heo e ical ounda ion, by ou lining
he mechanisms by which con ex in luences heal h and heal h dis ibu ion, p o iding
a basis o policy choices and empi ical analyses.
This amewo k was subs an ially inspi ed by Dide ichsen’s amewo k, d awing on
he indi idual pa hways ha he au ho ou lines o o m a basis o how con ex can
in luence hose pa hways. Unlike ha amewo k, howe e , his one ocuses on he
ole o con ex , and highligh s i s impac on popula ion heal h, on he one hand, and
on heal h dis ibu ion, on he o he . These impac s a e no mu ually exclusi e, as any
one change in con ex o con ex ual cha ac e is ic can in luence heal h and heal h
dis ibu ion h ough mul iple pa hways; howe e , i is hoped his dis inc ion suppo s
a e lec ion on how con ex ope a es and helps ill he ‘black box’ o con ex ual
e ec s on heal h (49).
3.3.1. Fi s Mechanism: Changes in O e all Heal h
The i s mechanism leads o changes in he o e all heal h o a popula ion. Using he
indi idual pa hway o Dide ichsen’s amewo k as a base, his mechanism can
ope a e by changing SES, exposu e o isk ac o s, o heal h s a us o indi iduals.
Figu e 6 shows hese h ee e ec s. The co e o he amewo k s a s om social
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
114
posi ion, which de e mines di e en ial exposu es; exposu es lead o di e en ial
ulne abili y; and inally disease o illness lead o di e en ial consequences, which
can ha e an impac back on social posi ion.
Figu e 6. Fi s mechanism: changes in o e all heal h.
The i s e ec e e s o how indi iduals’ social posi ion can be al e ed by con ex .
Fo example, when a coun y’s inances imp o e, po e y ends o decline, and
indi idual economic s a us o i s ci izens ends o imp o e, leading o o e all
imp o emen s in heal h. The second e ec e lec s changes in he exposu e o isk
ac o s; examples o his a e wa e luo ida ion o educ ions in ai pollu ion, which
can educe he exposu e o isk ac o s in an en i e popula ion, hus imp o ing i s
o e all heal h. The hi d e ec e e s o e en s ha change heal h s a us, such as when
an inno a i e ea men o a p e alen disease is disco e ed and made a ailable. All
hese e ec s ha e he po en ial o imp o e o e all popula ion heal h, ei he di ec ly,
by a ec ing indi iduals’ heal h o indi ec ly, by a ec ing social posi ion o exposu e
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
121
p og ams (con ex ual cha ac e is ic) ha e he po en ial o educe his inequali y, as
hey p o ide easie access o sc eening o people who o he wise migh no use i (69).
3.3.4 Summa y
The amewo k p oposed he e ou lines how con ex in luences heal h and heal h
dis ibu ion. I is p oposed ha con ex ope a es h ough wo mechanisms, one ha
changes o e all popula ion heal h ( hough e ec s on social posi ion, exposu e o isk
ac o s, and disease o illness) and ano he ha changes heal h dis ibu ion ( h ough
e ec s on social s a i ica ion, di e en ial exposu e, di e en ial ulne abili y, and
di e en ial consequences).
This amewo k seeks o ill a gap in he esea ch li e a u e, by which he pa hways
be ween he con ex and heal h and HI ha e no been ou lined be o e. I akes a s ep
o wa d om o he concep ual amewo ks, as i acknowledge he ole o con ex on
se e al di e en s eps be ween social posi ion and heal h ou comes. In his
amewo k, con ex does mo e han jus s a i y indi iduals o hei social posi ion.
The amewo k will hope ully be used as a basis o u u e policy and empi ical
analyses, helping cla i y he mechanisms by which con ex in luences heal h and i s
dis ibu ion.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
122
3.4. Applica ion o he Concep ual F amewo k
The amewo k desc ibed in he p e ious sec ion ( igu e 8) ou lines he mechanisms
by which con ex ual de e minan s can in luence heal h and heal h dis ibu ion. This
amewo k seeks o summa ize how his in luence ope a es, and can po en ially be
used as a basis o policy and empi ical analyses. In his chap e , he amewo k is
applied o h ee esea ch pape s om his disse a ion, in o de o illus a e how i can
be used in he in e p e a ion o e idence. I is no applied o one publica ion – he SR
– as his did no look a how one con ex ual de e minan in e ac s wi h indi idual
cha ac e is ics bu a he se ou he backg ound o he las piece o in es iga ion on
Po ugal (see able 2).
3.4.1. Social Capi al and Heal h in Eu opean Coun ies
This analysis showed a complex e ec o na ional-le el social capi al on indi idual
heal h, making i an in e es ing case s udy o he applica ion o he amewo k. The
amewo k ocuses on how he con ex ual de e minan (con ex ual social capi al) can
ha e an impac on popula ion heal h and heal h dis ibu ion, ope a ing h ough an
indi idual cha ac e is ic (indi idual social capi al). The key esul s we e:
• Con ex ual social capi al was no associa ed wi h indi idual heal h, and
• High con ex ual social capi al was associa ed wi h wo se heal h in low us
indi iduals and be e heal h in high us indi iduals.
These esul s show ha con ex ual social capi al had no impac on o e all popula ion
heal h. Wi hin he concep ual amewo k ( igu e 8), his means ha social capi al will
no ope a e h ough he ull a ows ( he i s mechanism – changes in o e all
popula ion heal h).
On he o he hand, con ex ual social capi al had a di e en ial e ec on di e en social
g oups, leading o changes in heal h dis ibu ion (dashed a ows, second mechanism –
changes in heal h dis ibu ion). This is p obably a e lec ion o how con ex ual social
capi al is no a esou ce enjoyed equally by all indi iduals – when high us
indi iduals a e he majo i y, he social capi al hey p oduce be ween hem is no
sha ed wi h he mino i y, low us indi iduals. Mo eo e , no only is his esou ce ou
o hei each, bu disc imina ion om he majo i y and dissemina ion o ‘bad social
capi al’ (such as ein o cing social no ms ha a e ha m ul o heal h) migh u he
damage a g oup ha is al eady ulne able. This di e en ial e ec can hus be a
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
123
consequence o p ocesses o ne wo k closu e, disc imina ion, and dissemina ion o
‘bad social capi al’. All hese p ocesses in essence e lec a di e en ial exposu e o
social capi al: high us indi iduals ha e access o con ex ual social capi al, while
low us indi iduals do no ; u he mo e, low us indi iduals may also be exposed
o ‘bad’ social capi al, u he damaging hei heal h.
Figu e 9. E ec o con ex ual social capi al on heal h dis ibu ion: esul s o he i s publica ion
(Campos-Ma os I, Sub amanian SV, Kawachi I. The ‘da k side’ o social capi al: us and sel - a ed
heal h in Eu opean coun ies. Eu opean Jou nal o Public Heal h. 2016;26(1):90-95).
I is impo an o no e ha applying he amewo k o only one analysis does no
exhaus all possible mechanisms by which one con ex ual de e minan ope a es.
Con ex ual social capi al can impac HI, as people a e no equally exposed o i s
e ec s, and i can also impac o e all popula ion heal h – as some au ho s a gue and
indeed ha e shown (4, 70). This amewo k is help ul o clea ly iden i y he
mechanisms unde s udy in an empi ical analysis, and u he sugges s o he
mechanisms ha may also exis and no ha e been de ec ed in ha pa icula analysis.
3.4.2. Social Mobili y and Heal h in Eu opean Wel a e Regimes
This analysis ocused on how he associa ion be ween social mobili y and heal h can
di e be ween Eu opean wel a e egimes. Impo an ly, i p o ided some e idence ha
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
124
heal h selec ion does no seem o be an impo an de e minan o HI in coun ies wi h
high le els o social mobili y. To apply he amewo k o his analysis, he ocus will
be on how he con ex ual de e minan (wel a e egime) can ha e an impac on heal h
and heal h dis ibu ion h ough he indi idual de e minan (social mobili y). The key
messages ega ding he impac o wel a e egime h ough social mobili y we e:
• The e we e signi ican di e ences in o e all heal h be ween di e en wel a e
egime ypes – Scandina ian coun ies showed he bes and o me USSR
coun ies he wo se esul s; and
• Indi iduals who we e upwa dly mobile showed be e heal h han hose who
we e socially s able, bu upwa d mobili y had a small impac in Scandina ian
coun ies, compa ed o a la ge impac in o me USSR coun ies.
Fi s , i is clea ha wel a e egime is associa ed wi h di e ences in o e all
popula ion heal h. The e a e many ways in which ce ain wel a e egimes can ha e an
impac on heal h – i can be ela ed o economic de elopmen , heal h se ices
p o ision, and cul u al aspec s, among o he s. One possible way is h ough social
mobili y. Poli ical choices, such as how o p o ide educa ion o how o edis ibu e
weal h, ha e he po en ial o b eak he in e -gene a ional ansmission o social
disad an age and imp o e he social posi ion o many, ega dless o hei pa en s’
social s anding. Thus, he ex en o social mobili y a ies subs an ially be ween
wel a e egimes (71) and can po en ially lead o be e socioeconomic ci cums ances
ac oss he popula ion. This is e iden by he obse a ion ha coun ies whe e social
mobili y is highes also end o ha e highe o e all educa ional le els (72). I is by
his e ec on social mobili y ha wel a e egimes, h ough imp o emen s in people’s
social posi ion, can lead o a be e (o wo se) le el o o e all popula ion heal h
( igu e 10).
Second, upwa d mobili y was associa ed wi h be e heal h in all coun ies, bu he
di e ence was conside ably bigge in o me USSR coun ies and smalles in
Scandina ian coun ies. This sugges s ha Scandina ian coun ies a e mo e e ec i e
a sepa a ing social mobili y om heal h. This means ha when indi iduals climb up
(down) he social ladde , hey a e mo e likely o ha e be e (wo se) heal h, especially
i hey li e in o me USSR coun ies. This can e lec a mechanism o social
s a i ica ion, as wel a e egimes de e mine how indi iduals a e placed in a socie y
and, consequen ly, hei heal h. F om a heal h selec ion pe spec i e, i may also mean
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
125
ha indi iduals who a e ill (heal hy) a e much mo e likely o all (climb) in he social
ladde in o me USSR coun ies, when compa ed o Scandina ian coun ies. This
second possibili y can e lec a mechanism o di e en ial consequences, as a pe son’s
heal h leads o changes in hei social posi ion.
Figu e 10. E ec s o wel a e egimes and social mobili y on heal h and heal h dis ibu ion: esul s o
he second publica ion (Campos-Ma os I, Kawachi I. Social mobili y and heal h in Eu opean coun ies:
does wel a e egime ype ma e ? Social Science and Medicine. 2015;142:241-248).
The esul s o his analysis e lec social mobili y’s e ec s on heal h and HI, since
mo e gene ous wel a e egimes no only show be e o e all heal h, bu also ewe
inequali ies be ween social mobili y g oups. Thus, wel a e egime, h ough i s e ec s
on social mobili y, can impac bo h he heal h and he heal h dis ibu ion o a
popula ion ( igu e 10). This analysis, o cou se, does no include o he e ec s ha
wel a e egimes can ha e bo h on heal h and HI, as i ocuses exclusi ely on he
e ec s ha a e media ed by social mobili y.
3.4.3. Shi ing De e minan s o Heal h Inequali ies in Po ugal
The ocus o his analysis was on how HI ha e changed in Po ugal o e he las
decade. Al hough we did no es he e ec o any con ex ual de e minan , we
in e p e ed he esul s conside ing he subs an ial economic changes ha we e
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
126
happening in he coun y a he ime. Fo he applica ion o he amewo k, he
ollowing key poin s summa ize he mos ele an esul s o his analysis:
• O e all popula ion heal h de e io a ed in Po ugal be ween 2010 and 2011;
• This de e io a ion was s eepe in he iches e cile, hus dec easing
inequali ies be ween income e ciles; and
• The main d i e o his dec ease was he change be ween ac i e and inac i e
g oups: while limi a ions we e mo e p e alen in inac i e people un il 2010,
hey became mo e p e alen in ac i e people a e his yea .
The o e all de e io a ion in popula ion heal h in Po ugal be ween 2010 and 2011 is
likely o be ela ed o o e all economic changes happening a he ime. These e en s,
such as implemen a ion o highly publicized aus e i y measu es, can ope a e h ough a
s ess-de e mined pa hway, as a clima e o unce ain y can lead o s ess and,
consequen ly, poo e heal h, leading o wo se heal h ou comes ac oss he popula ion.
In he amewo k, his can be in e p e ed as an e ec on exposu e o a isk ac o :
economic changes a e he con ex ual de e minan ha lead o an inc ease in he
exposu e o a isk ac o – s ess – hus ha ing an e ec on he whole popula ion’s
heal h ( igu e 11). Howe e , no e e yone eac ed he same way o his unce ain y. In
ac , iche people ( he iches e cile) seemed o su e he g ea es hi . This was
g ea ly media ed by he ac ha ac i e people – who also ended o be iche – had a
highe p e alence o limi a ions a e 2010 han inac i e people. Despi e no ha ing
o mally es ed his, we hypo hesized ha wo mechanisms migh be behind his
change. Fi s , people om highe socioeconomic classes (who end o ha e highe
incomes) may no be as used o dealing wi h unce ain y as people om lowe
socioeconomic classes a e. To hem, he p ospec o unce ain imes ahead could ha e
led o mo e in ense s ess eac ions and o an inabili y o deal wi h p ac ical day- o-
day p oblems on a mo e es ic ed budge . This i s mechanism can be iden i ied in
he amewo k as di e en ial ulne abili y, as all g oups we e exposed o unce ain y
and s ess, bu – pe haps coun e in ui i ely – high SES people we e mo e ulne able,
a leas du ing a ce ain pe iod o he ime. Second, conside ing he high emig a ion
a es Po ugal was going h ough a he ime (73), he g oup o ac i e people who was
‘le behind’ migh ha e had disp opo iona ely high a es o limi a ions, as mig a ion
is known o be a selec i e p ocess by which heal hie people end o mig a e mo e
(74). This second mechanism is a consequence o changes in he composi ion o he
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
127
popula ion. This can be seen as a change in social s a i ica ion, as changes in he
economic con ex led o changes in how weal h and powe we e dis ibu ed o
di e en social posi ions.
Figu e 11. E ec s o mac oeconomic changes on heal h and heal h dis ibu ion: esul s o he ou h
publica ion (Campos-Ma os I, Russo G, Gonçal es L. (accep ed o publica ion). Shi ing de e minan s
o heal h inequali ies in uns able imes: Po ugal as a case s udy. Accep ed o publica ion in he
Eu opean Jou nal o Public Heal h in May 2017. DOI: h ps://dx.doi.o g/10.1093/eu pub/ckx080).
O e all, his analysis sugges s ha economic and social changes in a coun y can lead
o changes in heal h and heal h dis ibu ion h ough h ee mechanisms: social
s a i ica ion, exposu e o isk ac o s, and di e en ial ulne abili y o hose isk
ac o s ( igu e 11). Once again, his does no p o ide an exhaus i e desc ip ion o
how economic c ises impac heal h and heal h dis ibu ion, bu sugges s some o he
mechanisms ha may ope a e and ames he indings in a la ge con ex .
3.4.4. Summa y
The amewo k p oposed he e aims o ou line he mechanisms ha connec con ex ual
cha ac e is ics o popula ion heal h and heal h dis ibu ion. I was applied o he
analysis o h ee con ex ual de e minan s: social capi al, wel a e egime, and
mac oeconomic changes. Each o hese de e minan s in luenced heal h ou comes and
hei dis ibu ion h ough a ious mechanisms: di e en ial exposu e (social capi al);
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
128
social s a i ica ion, social posi ion, and di e en ial consequences (wel a e egimes);
and social s a i ica ion, exposu e, and di e en ial ulne abili y (economic c isis).
The amewo k p o ed a use ul ool o ame hese publica ions, in which con ex ual
de e minan s we e explo ed. In pa icula , i acknowledged he impo ance o con ex
in se e al s eps in o de o in luence bo h heal h and HI. In u u e esea ch, i can
p o ide a s uc u e o acili a e a e lec ion abou he heo e ical basis ha unde sco es
analyses, hus s eng hening hem and he a gumen s hey p opose.
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
129
3.5. Con ibu ion o Policy and Resea ch
3.5.1. Rega ding Heal h Inequali ies
This esea ch has p esen ed a new amewo k on how con ex can shape heal h and
heal h dis ibu ion. This amewo k is buil on a amewo k p oposed by Dide ichsen
e al. ( igu e 3) (52), and inco po a es a ew impo an di e ences om he o iginal
amewo k. Fi s ly, i explici ly ocuses on con ex . Fo Dide ichsen, con ex was
esponsible o social s a i ica ion and policies. In he amewo k pu o wa d he e, i
is p oposed ha con ex is seen is a b oade pe spec i e, encompassing also physical
and o he social elemen s (besides policies). I is also p oposed ha con ex no only
con ibu es by c ea ing a sys em o social s a i ica ion and policies, bu also by
in luencing all he o he s eps o he pa hway be ween social posi ion and heal h
ou comes. Fu he mo e, his amewo k highligh s ha con ex can in luence heal h
and heal h dis ibu ion, and i does so by di e en mechanisms.
Ano he impo an dis inc ion om Dide ichsen’s wo k is ha in he o me
amewo k di e en ial ulne abili y is he accumula ion o ha m ul isk ac o s in a
pa icula popula ion g oup. In applying he new amewo k o he analyses, i was
ound ha di e en ial ulne abili y does no necessa ily mean ha he same
indi iduals a e always ulne able. Simila ly, di e en ial exposu es and consequences
do no necessa ily mean ha he poo es o leas educa ed will always be mo e
exposed o isk ac o s o su e g ea ly he consequences o ill-heal h. In ou wo k, i
is p oposed o ede ine he e m ‘di e en ial’ o mean only ha e ec s a e di e en in
di e en socioeconomic g oups, wi hou sugges ing a di ec ion o he e ec .
Hope ully, his amewo k can be used in u u e esea ch p ojec s o collec e idence
o he e ec o a con ex ual de e minan . Fo example, o pe o m a e iew o how
economic g ow h can impac on heal h and heal h dis ibu ion, he collec ed e idence
can be o ganized using his amewo k. This amewo k could also help esea che s
ou line a clea heo e ical basis o hei wo k, hus building a s onge e idence base
a ound he opic o hei esea ch. This is pa icula ly impo an conside ing he lack
o a clea heo y abou he mechanisms by which con ex ope a es has been one o he
ac o s hampe ing he s udy o con ex ual in luences on heal h (75).
Rega ding i s con ibu ion o policy making, as i builds on and u he he cu en
heo ies on con ex ual e ec s on heal h, he amewo k may also help policy make s
The ela ionship be ween con ex and heal h inequali ies Chap e 3. Discussion and Conclusions
130
unde s and he op ions a ailable o ackle speci ic aspec s o HI. Pa icula ly, i could
p o e a use ul ins umen o equali y impac assessmen s – he analysis o policies
ha ies o ensu e hey do no disc imina e agains any ulne able g oup (76).
Besides being a p ac ical ins umen o esea che s and policy make s, he
amewo k will hope ully con ibu e o he ising end o a di e en hinking abou
HI. Namely, i emphasizes how HI a e no a p oduc o indi idual cha ac e is ics
alone, bu a consequence o he in e ac ion be ween con ex and indi iduals. This can
ha e impo an implica ions on how HI a e ackled – om a ocus on indi idual
beha iou change, policy make s should also hink abou enabling and disabling
cha ac e is ics ha con ex s can p o ide o in luence hose beha iou changes.
Ano he con ibu ion o he p esen esea ch is he concu en analysis o se e al
indi idual SES cha ac e is ics as an oppo uni y o explo e he mechanisms behind
HI. This ype o analysis is no common, bu p o ed e y p oduc i e. In his analysis,
his allowed o he explo a ion o wha migh ha e been behind he dec ease in HI in
Po ugal a e 2010, hus laying g oundwo k o u he esea ch on he opic. This
me hod p o ided in e es ing le els o analysis, and could be ep oduced in u u e
analyses in o he con ex s.
3.5.2. Rega ding Eu ope
This esea ch also p o ided some con ibu ion o he unde s anding o HI in Eu opean
coun ies. The pe sis ence o HI in Eu ope has been called a ‘pa adox’ and social
mobili y has been pu o wa d as one o a ew possible explana ions (10). The p esen
indings on social mobili y in di e en wel a e egimes in Eu ope show ha his is
highly unlikely, o coun ies wi h high social mobili y would show a leas as high
inequali ies in heal h be ween mobili y g oups as coun ies wi h low mobili y, which
was no he case. This can help mo e o wa d he explo a ion o he ‘pa adox’, as
o he explana ions a e now mo e likely and should be u he in es iga ed. In e ms o
policy-making, hese indings sugges ha i is possible o mi iga e he associa ion
be ween social mobili y and heal h. Al hough all wel a e egimes showed some kind
o associa ion be ween social mobili y and SAH, some we e signi ican ly smalle ,
sugges ing ha i is possible o sepa a e he wo mo e e icien ly, and ha he answe
lies in he di e ences be ween he wel a e egimes.