Carles Muntaner

Politics and health outcomes

The aim of this study was to examine the complex interactions between political traditions, policies, and public health outcomes, and to find out whether different political traditions have been associated with systematic patterns in population health over time. We analysed a number of political, economic, social, and health variables over a 50-year period, in a set of wealthy countries belonging to the Organisation for Economic Co-operation and Development (OECD). Our findings support the hypothesis that the political ideologies of governing parties affect some indicators of population health. Our analysis makes an empirical link between politics and policy, by showing that political parties with egalitarian ideologies tend to implement redistributive policies. An important finding of our research is that policies aimed at reducing social inequalities, such as welfare state and labour market policies, do seem to have a salutary effect on the selected health indicators, infant mortality and life expectancy at birth.

Social class and self-reported health status among men and women: what is the role of work organisation, household material standards and household labour?

Social class understood as social relations of ownership and control over productive assets taps into parts of the social variation in health that are not captured by conventional measures of social stratification. The objectives of this study are to analyse the association between self-reported health status and social class and to examine the role of work organisation, material standards and household labour as potential mediating factors in explaining this association. We used the Barcelona Health Interview Survey, a cross-sectional survey of 10,000 residents of the citys non-institutionalised population in 2000. This was a stratified sample, strata being the 10 districts of the city. The present study was conducted on the working population, aged 16-64 years (2345 men and 1874 women). Social class position was measured with Erik Olin Wrights indicators according to ownership and control over productive assets. The dependent variable was self-reported health status. The independent variables were social class, age, psychosocial and physical working conditions, job insecurity, type of labour contract, number of hours worked per week, possession of appliances at home, as well as household labour (number of hours per week, doing the housework alone and having children, elderly or disabled at home). Several hierarchical logistic regression models were performed by adding different blocks of independent variables. Among men the prevalence of poor reported health was higher among small employers and petit bourgeois, supervisors, semi-skilled (adjusted odds ratio-aOR: 4.92; 95% CI: 1.88-12.88) and unskilled workers (aOR: 7.69; 95%CI: 3.01-19.64). Work organisation and household material standards were associated with poor health status with the exception of number of hours worked per week. Work organisation variables were the main explanatory variables of social class inequalities in health, although material standards also contributed. Among women, only unskilled workers had poorer health status than the referent category of manager and skilled supervisors (aOR: 3.25; 95%CI: 1.37-7.74). All indicators of work organisation and household material standards reached statistical significance, excepting the number of hours worked per week. In contrast to men, among women the number of hours per week of household labour was associated with poor health status (aOR: 1.02; 95% CI: 1.01-1.03). Showing a different pattern from men in the full model, household material deprivation and hours of household labour per week were associated with poor health status among women. Our findings suggest that among men, part of the association between social class positions and poor health can be accounted for psychosocial and physical working conditions and job insecurity. Among women, the association between the worker (non-owner, non-managerial, and un-credentiated) class positions and health is substantially explained by working conditions, material well being at home and amount of household labour.

Income inequality, social cohesion, and class relations: a critique of Wilkinson's neo-Durkheimian research program

Wilkinsons “income inequality and social cohesion” model has emerged as a leading research program in social epidemiology. Public health scholars and activists working toward the elimination of social inequalities in health can find several appealing features in Wilkinsons research. In particular, it provides a sociological alternative to former models that emphasize poverty, health behaviors, or the cultural aspects of social relations as determinants of population health. Wilkinsons model calls for social explanations, avoids the subjectivist legacy of U.S. functionalist sociology that is evident in “status” approaches to understanding social inequalities in health, and calls for broad policies of income redistribution. Nevertheless, Wilkinsons research program has characteristics that limit its explanatory power and its ability to inform social policies directed toward reducing social inequalities in health. The model ignores class relations, an approach that might help explain how income inequalities are generated and account for both relative and absolute deprivation. Furthermore, Wilkinsons model implies that social cohesion rather than political change is the major determinant of population health. Historical evidence suggests that class formation could determine both reductions in social inequalities and increases in social cohesion. Drawing on recent examples, the authors argue that an emphasis on social cohesion can be used to render communities responsible for their mortality and morbidity rates: a community-level version of “blaming the victim.” Such use of social cohesion is related to current policy initiatives in the United States and Britain under the New Democrat and New Labor governments.

Social class, assets, organizational control and the prevalence of common groups of psychiatric disorders.

This study provides an update on the association between social class and common types of psychiatric disorder in the US. In addition to usual measures of social class, we provide hypotheses for the expectation that assets and organizational control are associated with specific varieties of psychiatric disorders (mood, anxiety, alcohol and drug use disorders). We analyzed two surveys. The National Comorbidity Survey conducted in 1990-1992 yielded 12-month prevalence rates in a probability sample of 8098 respondents in the 48 contiguous states. The Epidemiologic Catchment Area Follow-up conducted in 1993-1996 provided similar rates among 1920 East Baltimore residents. Analyses of the National Comorbidity Survey showed an inverse association between financial and physical assets and mood, anxiety, alcohol, and drug disorders. The Epidemiologic Catchment Area Followup provided additional evidence for the inverse association between financial and physical assets and anxiety, alcohol and drug disorders. Also in the Epidemiologic Catchment Area, lower level supervisors presented higher rates of depression and anxiety disorders than higher level managers. Inequalities in assets and organizational control, as well as typical measures of social class, are associated with specific psychiatric disorders. These constructs can provide additional explanations for why social inequalities in psychiatric disorders occur.

The Importance of the Political and the Social in Explaining Mortality Differentials among the Countries of the OECD, 1950–1998

This article analyzes (within the conceptual frame defined in the previous article) the impact of political variables such as time of government by political parties (social democratic, Christian democratic or conservative, liberal, and ex-dictatorial that have governed the OECD countries during the 1950–1998 period) and their electoral support on (1) redistributional policies in the labor market and in the welfare state; (2) the income inequalities measured by Theil and Gini indexes; and (3) health indicators, such as infant mortality and life expectancy. This analysis is carried out statistically by a bivariate and a multivariate analysis (a pooled cross-sectional study). Both analyses show that political variables play an important role in defining how public and social policies determine the levels of inequalities and affect the level of infant mortality. In general, political parties more committed to redistributional policies, such as social democratic parties, are the most successful in reducing inequalities and improving infant mortality. Less evidence exists, however, on effects on life expectancy. The article also quantifies statistically the relationship between the political and the policy variables and between these variables and the dependent variables—that is, the health indicators.

Health-system reform and universal health coverage in Latin America

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Associations between temporary employment and occupational injury: what are the mechanisms?

Objective: To determine whether observed higher risks of occupational injury among temporary workers are due to exposure to hazardous working conditions and/or to lack of job experience level. Methods: Data systematically recorded for 2000 and 2001 by the Spanish Ministry of Labour and Social Affairs on fatal and non-fatal traumatic occupational injuries were examined by type of employment and type of accident, while adjusting for gender, age, occupation, and length of employment in the company. In the study period there were 1500 fatal and 1 806 532 non-fatal traumatic occupational injuries that occurred at the workplace. Incidence rates and rate ratios (RR) were estimated using Poisson regression models. Results: Temporary workers showed a rate ratio of 2.94 for non-fatal occupational injuries (95% CI 2.40 to 3.61) and 2.54 for fatal occupational injuries (95% CI 1.88 to 3.42). When these associations were adjusted by gender, age, occupation, and especially length of employment, they loose statistic significance: 1.05 (95% CI 0.97 to 1.12) for non-fatal and 1.07 (95% CI 0.91 to 1.26) for fatal. Conclusions: Lower job experience and knowledge of workplace hazards, measured by length of employment, is a possible mechanism to explain the consistent association between temporary workers and occupational injury. The role of working conditions associated with temporary jobs should be assessed more specifically.

Socioeconomic status and depressive syndrome: the role of inter- and intra-generational mobility, government assistance, and work environment.

This paper assesses the hypothesis that depressive syndrome is associated with socioeconomic status, using longitudinal data from the Baltimore Epidemiologic Catchment Area Followup. Socioeconomic measures include those used in most studies of status attainment, as well as measures of financial dependence, non-job income, and work environment. Analyses include inter- and intra-generational mobility, and replicate the basic aspects of the status attainment process, as well as psychiatric epidemiologic findings regarding gender, family history of depression, life events, and depressive syndrome. But the involvement of depressive syndrome in the process of status attainment, either as cause or consequence, is small and not statistically significant. There are strong effects of financial dependence and work environment on depressive syndrome. The findings shed doubt on the utility of the causation/selection/drift model for depression, to the extent it is based on linear relationships and socioeconomic rank at the macro level, while lending credibility to social-psychologically oriented theories of work environment, poverty, and depression.

Social capital, disorganized communities, and the third way: Understanding the retreat from structural inequalities in epidemiology and public health

The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. The authors review current hypotheses on the social capital and health link, and examine the empirical evidence and its implications for health policy. The construct of social capital employed in the public health literature lacks depth compared with its uses in social science. It presents itself as an alternative to materialist structural inequalities (class, gender, and race) and invokes a romanticized view of communities without social conflict that favors an idealist psychology over a psychology connected to material resources and social structure. The evidence on social capital as a determinant of better health is scant or ambiguous. Even if confirmed, such hypotheses call for attention to social determinants beyond the proximal realm of individualized sociopsychological infrastructure. Social capital is used in public health as an alternative to both state-centered economic redistribution and party politics, and represents a potential privatization of both economics and politics. Such uses of social capital mirror recent “third way” policies in Germany, the United Kingdom, and United States. If third way policies lose support in Europe, the prominence of social capital there might be short lived. In the United States, where the working class is less likely to influence social policy, interest in social capital could be longer lived or could drift into academic limbo like other psychosocial constructs once heralded as the next big idea.

PSYCHOSOCIAL WORK ENVIRONMENT IN HUMAN SERVICE ORGANIZATIONS: A CONCEPTUAL ANALYSIS AND DEVELOPMENT OF THE DEMAND-CONTROL MODEL

This paper concerns two models that were introduced in two different research domains during the 1970s. The first model regards human service organizations (HSO) as a specific type of organization. The second model, the demand-control model (DC model), concerns the joint effects of job demands and job control on worker health. In the HSO model, there are analyses of the content of jobs, considering the specific characteristics of HSOs, but little is said about the health effects of such work. Those effects stand in focus in the demand-control model. The aim of this paper is to analyze the relevance of the DC model for human service organizations. The paper argues that the object of human service work-the client relation-makes a difference for demand and control in the job. Demand is analyzed into work load, emotional demands and role conflict. Control is divided into administrative control, outcome control, choice of skills, closeness of supervision, control within and over a situation and ideological control. The conclusion is that in applications on HSOs, the basic concepts of the DC model must be developed.