Monica Åberg Yngwe

The role of welfare state principles and generosity in social policy programmes for public health: an international comparative study

BACKGROUND Many important social determinants of health are also the focus for social policies. Welfare states contribute to the resources available for their citizens through cash transfer programmes and subsidised services. Although all rich nations have welfare programmes, there are clear cross-national differences with respect to their design and generosity. These differences are evident in national variations in poverty rates, especially among children and elderly people. We investigated to what extent variations in family and pension policies are linked to infant mortality and old-age excess mortality. METHODS Infant mortality rates and old-age excess mortality rates were analysed in relation to social policy characteristics and generosity. We did pooled cross-sectional time-series analyses of 18 OECD (Organisation for Economic Co-operation and Development) countries during the period 1970-2000 for family policies and 1950-2000 for pension policies. FINDINGS Increased generosity in family policies that support dual-earner families is linked with lower infant mortality rates, whereas the generosity in family policies that support more traditional families with gainfully employed men and homemaking women is not. An increase by one percentage point in dual-earner support lowers infant mortality by 0.04 deaths per 1000 births. Generosity in basic security type of pensions is linked to lower old-age excess mortality, whereas the generosity of earnings-related income security pensions is not. An increase by one percentage point in basic security pensions is associated with a decrease in the old age excess mortality by 0.02 for men as well as for women. INTERPRETATION The ways in which social policies are designed, as well as their generosity, are important for health because of the increase in resources that social policies entail. Hence, social policies are of major importance for how we can tackle the social determinants of health.

Exploring relative deprivation: is social comparison a mechanism in the relation between income and health?

During the last decade there has been a growing interest in the relation between income and health. The discussion has mostly focused on the individuals relative standing in the income distribution with the implicit understanding that the absolute level of income is not as relevant when the individuals basic needs are fulfilled. This study hypothesises relative deprivation to be a mechanism in the relation between income and health in Sweden: being relatively deprived in comparison to a reference group causes a stressful situation, which might affect self-rated health. Reference groups were formed by combining indicators of social class, age and living region, resulting in 40 reference groups. Within each of these groups a mean income level was calculated and individuals with an income below 70% of the mean income level in the reference group were considered as being relatively deprived. The results showed that more women than men were relatively deprived, but the effect of relative deprivation on self-rated health was more pronounced among men than among women. In order to estimate the importance of the effect of relative income versus the effect of absolute income, some analyses on the effect of relative deprivation on self-rated health were also carried out within different absolute income levels. When restricting the analysis to the lowest 40% of the income span the effect of relative deprivation almost disappeared. Relative deprivation may have a significant relation to health among men. However, for the 40% with the lowest income in the population the effect of relative deprivation on health is considerably reduced, possibly due to the more prominent relation between low absolute income and poor health.

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

BackgroundThe past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings.MethodsThree reviews and relevant bibliographies were manually explored in order to find studies for the review. Related articles were searched for in PubMed, Web of Science and Google Scholar. Database searches were done in PubMed and Web of Science. The search period was restricted to 2005-01-01 to 2013-02-28. Fifty-four studies met the inclusion criteria.ResultsThree main approaches to comparative welfare state research are identified; the Regime approach, the Institutional approach, and the Expenditure approach. The Regime approach is the most common and regardless of the empirical regime theory employed and the amendments made to these, results are diverse and contradictory. When stratifying studies according to other features, not much added clarity is achieved. The Institutional approach shows more consistent results; generous policies and benefits seem to be associated with health in a positive way for all people in a population, not only those who are directly affected or targeted. The Expenditure approach finds that social and health spending is associated with increased levels of health and smaller health inequalities in one way or another but the studies are few in numbers making it somewhat difficult to get coherent results.ConclusionsBased on earlier reviews and our results we suggest that future research should focus less on welfare regimes and health inequalities and more on a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources.

Changing health inequalities in a changing society? Sweden in the mid-1980s and mid-1990s

Whereas the end of the 1980s was characterized by an economic boom, the early 1990s saw the worst recession since the 1930s. In Sweden, the crisis that started in the fall of 1991 and culminated in 1995 meant dramatically increased unemployment rates followed by cutbacks in welfare state programs. In addition, other major changes in economic and political conditions have taken place during this period, including tax reforms and EU membership. Although public health as well as health inequalities are likely to be linked with these kinds of macro changes, it is unclear what types of changes in health and health inequalities one would expect. In this paper analyses of Swedish data on health inequalities in the periods 1986-87 and 1994-95 are undertaken on the basis of the Swedish Surveys of Living Conditions. The main finding is that overall health levels as well as differences in health between men and women, different age groups, educational groups, social classes, and employment status groups have remained constant.

Relative deprivation and mortality--a longitudinal study in a Swedish population of 4.7 million, 1990-2006.

BackgroundRelative deprivation has previously been discussed as a possible mechanism underlying the income-health relation. The idea is that income matters to the individual’s health, over and above the increased command over resources, as the basis of social comparisons between a person and his or her reference group. The following study aimed to analyze the role of individual-level relative deprivation for all-cause mortality in the Swedish population. The Swedish context, characterized by relatively small income inequalities and promoting values as egalitarianism and equality, together with a large data material provide unique possibilities for analyzing the hypothesized mechanism.MethodsThe data used are prospective longitudinal data from the Swedish population and based on a linkage of registers. Restricting selection to individuals 25–64 years, alive January 1st 1990, gave 4.7 million individuals, for whom a mortality follow-up was done over a 16-year period. The individual level relative deprivation was measured using the Yitzhaki index, calculating the accumulated shortfall between the individual’s income and the income of all other’s in the person’s reference group. All-cause mortality was used as the outcome measure.ResultsRelative deprivation, generated through social comparisons, is one possible mechanism within the income and health relation. The present study analyzed different types of objectively defined reference groups, all based on the idea that people compare themselves to similar others. Results show relative deprivation, when measured by the Yitzhaki index, to be significantly associated with mortality. Also, we found a stronger effect among men than among women. Analyzing the association within different income strata, the effect was shown to be weak among the poorest. Revealing the importance of relative deprivation for premature mortality, over and above the effect of absolute income, these results resemble previous findings.ConclusionRelative deprivation, based on social comparisons of income, is significantly associated with premature mortality in Sweden, over and above the effect of absolute income. Also, it was found to be more important among men, but weak among the poorest.

Widowhood and the risk of psychiatric care, psychotropic medication and all-cause mortality: A cohort study of 658,022 elderly people in Sweden

Objectives: To study the effect of widowhood on the risk of psychiatric care, psychotropic medication and mortality, and to study if the effect is modified by educational level. Method: A nationwide, register-based cohort study. All married or widowed individuals aged 75 and older who were alive and registered in Sweden on 31 December 2004 and still registered on 31 December 2005. A total of 658,022 individuals were included in the study and followed in 2006. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Results: Loss of spouse increased the risk of outpatient psychiatric visits, psychotropic medication and all-cause mortality. Prescribed psychotropic medication was more common among those newly bereaved, adjusted OR of 1.46 (95% CI 1.41–1.50), compared to those married. For those widowed for a longer period, the corresponding estimate was 1.12 (95% CI 1.11–1.14). The OR for all-cause mortality was 1.18 (95% CI 1.11–1.26). The analyses also indicated different effects on inpatient care depending on educational level. Conclusion: Loss of spouse increases the risk of people getting psychiatric care, both for severe and minor psychiatric conditions. The effect seems to differ depending on educational level. Further studies are needed to disentangle the mechanism behind the effects of each measurement of psychiatric conditions and how these are affected by educational level.

On the importance of internalized consumption norms for ill health

Aim: Relative deprivation has in previous studies been put forward as a possible mechanism in the income and health relation. To capture the importance of social comparisons analytically has been problematic due to the difficulty in identifying reference groups of significance for the individual. The authors suggest that using the individuals own preferences, arguing these to be preferences of both society and reference groups internalized by the individual, may partly bridge this problem. Methods: The study is based on the Swedish Survey of Living Conditions 1998 including a list of 37 consumption items and activities. By counting the items that the individual cannot afford, but at the same time considers to be a necessity and something that all adults should afford, a measure of self-rated deprivation (SRD) is constructed. The outcome measure used is less than good self-rated health and limiting longstanding illness. Men and women aged 25—64 years are included. Results: Over the different groups of self-rated deprivation a clear gradient in ill health, for both health measures, was found among women. The results for men seemed to dichotomize between non-deprived and those deprived on at least one item. The logistic regression models showed that even after adjusting for socioeconomic group and cash margin, there was a significant effect of self-rated deprivation. Conclusions: A significant relation was found between self-rated deprivation and ill health, both less than good health and limiting longstanding illness. Self-rated deprivation had a stronger impact on women than men.

Rising inequality in mortality among working-age men and women in Sweden: a national registry-based repeated cohort study, 1990–2007

Background In the past two decades, health inequality has persisted or increased in states with comprehensive welfare. Methods We conducted a national registry-based repeated cohort study with a 3-year follow-up between 1990 and 2007 in Sweden. Information on all-cause mortality in all working-age Swedish men and women aged between 30 and 64 years was collected. Data were subjected to temporal trend analysis using joinpoint regression to statistically confirm the trajectories observed. Results Among men, age-standardised mortality rate decreased by 38.3% from 234.9 to 145 (per 100 000 population) over the whole period in the highest income quintile, whereas the reduction was only 18.3% (from 774.5 to 632.5) in the lowest quintile. Among women, mortality decreased by 40% (from 187.4 to 112.5) in the highest income group, but increased by 12.1% (from 280.2 to 314.2) in the poorest income group. Joinpoint regression identified that the differences in age-standardised mortality between the highest and the lowest income quintiles decreased among men by 18.85 annually between 1990 and 1994 (p trend=0.02), whereas it increased later, with a 2.88 point increase per year (p trend <0.0001). Among women, it continuously increased by 9.26/year (p trend <0.0001). In relative terms, age-adjusted mortality rate ratios showed a continuous increase in both genders. Conclusions Income-based inequalities among working-age male and female Swedes have increased since the late 1990s, whereas in absolute terms the increase was less remarkable among men. Structural and behavioural factors explaining this trend, such as the economic recession in the early 1990s, should be studied further.