Nico Vonneilich

The mediating effect of social relationships on the association between socioeconomic status and subjective health – results from the Heinz Nixdorf Recall cohort study

BackgroundSocioeconomic status (SES) is an important determinant of population health. Explanatory approaches on how SES determines health have so far included numerous factors, amongst them psychosocial factors such as social relationships. However, it is unclear whether social relationships can help explain socioeconomic differences in general subjective health. Do different aspects of social relationships contribute differently to the explanation? Based on a cohort study of middle and older aged residents (45 to 75 years) from the Ruhr Area in Germany our study tries to clarify the matter.MethodsFor the analyses data from the population-based prospective Heinz Nixdorf Recall (HNR) Study is used. As indicators of SES education, equivalent household income and occupational status were employed. Social relations were assessed by including structural as well as functional aspects. Structural aspects were estimated by the Social Integration Index (SII) and functional aspects were measured by availability of emotional and instrumental support. Data on general subjective health status was available for both baseline examination (2000–2003) and a 5-year follow-up (2006–2008). The sample consists of 4,146 men and women. Four logistic regression models were calculated: in the first model we controlled for age and subjective health at baseline, while in models 2 and 3, either functional or structural aspects of social relationships were introduced separately. Model 4 then included all variables. As former studies indicated different health effects of SES and social relations in men and women, analyses were conducted with the overall sample as well as for each gender alone.ResultsProspective associations of SES and subjective health were reduced after introducing social relationships into the regression models. Percentage reductions between 2% and 30% were observed in the overall sample when all aspects of social relations were included. The percentage reductions were strongest in the lowest SES group. Gender specific analyses revealed mediating effects of social relationships in women and men. The magnitude of mediating effects varied depending on the indicators of SES and social relations.ConclusionsSocial relationships substantially contribute to the explanation of SES differences in subjective health. Interventions for improving social relations which especially focus on socially deprived groups are likely to help reducing socioeconomic disparities in health.

Does socioeconomic status affect the association of social relationships and health? A moderator analysis

BackgroundSocial relations have repeatedly been found to be an important determinant of health. However, it is unclear whether the association between social relations and health is consistent throughout different status groups. It is likely that health effects of social relations vary in different status groups, as stated in the hypothesis of differential vulnerability. In this analysis we explore whether socioeconomic status (SES) moderates the association between social relations and health.MethodsIn the baseline examination of the Heinz Nixdorf Recall study, conducted in a dense populated Western German region (N = 4,814, response rate 56%), SES was measured by income and education. Social relations were classified by using both structural as well as functional measures. The Social Integration Index was used as a structural measure, whilst functional aspects were assessed by emotional and instrumental support. Health was indicated by self-rated health (1 item) and a short version of the CES-D scale measuring the frequency of depressive symptoms. Based on logistic regression models we calculated the relative excess risk due to interaction (RERI) which indicates existing moderator effects.ResultsOur findings show highest odds ratios (ORs) for both poor self-rated health and more frequent depressive symptoms when respondents have a low SES as well as inappropriate social relations. For example, respondents with low income and a low level of social integration have an OR for a high depression score of 2.85 (95% CI 2.32-4.49), compared to an OR of 1.44 (95% CI 1.12-1.86) amongst those with a low income but a high level of social integration and an OR of 1.72 (95% CI 1.45-2.03) amongst respondents with high income but a low level of social integration. As reference group those reporting high income and a high level of social integration were used.ConclusionsThe analyses indicate that the association of social relations and subjective health differs across SES groups as we find moderating effects of SES. However, results are inconsistent as nearly all RERI scores are positive but do not reach a significant level. Also moderating effects vary between women and men and depending on the indicators of SES and social relations used. Thus, the hypothesis of differential vulnerability can only partially be supported. In terms of practical implications, psychosocial and health interventions aiming towards the enhancement of social relations should especially consider the situation of the socially deprived.

Do social relations explain health inequalities? Evidence from a longitudinal survey in a changing eastern German region

ObjectivesThis study explores the contribution of social relations to explain inequalities in self-rated health in a changing north-eastern German region. So far, there are only few studies that analysed the mediating effects of social relations in a longitudinal design.MethodsWe used data from the Study of Health in Pomerania (SHIP) consisting of 3,300 randomly selected men and women at baseline (2001), and at the 5-year follow-up (2006). Indicators of social inequality were education, equivalent household income and occupational status. Social relations were estimated by the Social Integration Index (SII) and the perceived instrumental and emotional support. Self-rated general health was assessed at both waves of data collection.ResultsDepending on the indicators used, social relations explain up to 35% of the inequalities in self-rated health. Changes in odds ratios are slightly more pronounced when education and income are used as inequality indicator and when adjusting for the SII.ConclusionsOverall findings suggest that social relations are an important explanatory factor for health inequalities in a deprived German region.

Gesundheitliche Ungleichheit im Alter

The aim of this article is to provide an overview of the current state of research concerning health inequalities among the aged. First, health inequalities are introduced as a general phenomenon. Then, the magnitude of inequalities in elderly populations is described for different health indicators. In particular, analyses of the association between education and depressive symptoms based on a European dataset are presented. Subsequently, different hypotheses on age differences in health inequalities and possible explanations for social inequalities in health in elderly populations are discussed. Finally, some consequences for health policy, which can be derived from current research, are outlined.ZusammenfassungZiel des vorliegenden Beitrags ist es, einen Überblick über die aktuelle Forschungslage zum Thema gesundheitliche Ungleichheiten im höheren Lebensalter zu geben. Hierzu wird zunächst allgemein das Phänomen der gesundheitlichen Ungleichheit eingeführt. Darauf aufbauend wird das Ausmaß gesundheitlicher Ungleichheiten im höheren Lebensalter im Hinblick auf unterschiedliche Gesundheitsindikatoren beschrieben. Dabei werden auch eigene Analysen zum Zusammenhang von Bildung und depressiven Symptomen im Alter anhand eines europäischen Datensatzes präsentiert. Im darauf folgenden Abschnitt wird der Frage nachgegangen, inwieweit sich gesundheitliche Ungleichheiten mit zunehmendem Alter verändern. Anschließend wird auf mögliche Erklärungen für den Zusammenhang zwischen sozialer Ungleichheit und Gesundheit im höheren Lebensalter eingegangen. Zum Abschluss werden einige Schlussfolgerungen für die Gesundheitspolitik skizziert, die sich aus dem Stand der Forschung ableiten lassen.AbstractThe aim of this article is to provide an overview of the current state of research concerning health inequalities among the aged. First, health inequalities are introduced as a general phenomenon. Then, the magnitude of inequalities in elderly populations is described for different health indicators. In particular, analyses of the association between education and depressive symptoms based on a European dataset are presented. Subsequently, different hypotheses on age differences in health inequalities and possible explanations for social inequalities in health in elderly populations are discussed. Finally, some consequences for health policy, which can be derived from current research, are outlined.

Are health care inequalities unfair? A study on public attitudes in 23 countries.

BackgroundIn this article we focus on the following aims: (1) to analyze national and welfare state variations in the public perception of income-related health care inequalities, (2) to analyze associations of sociodemographic, socioeconomic, health-related, and health care factors with the perception of health care inequalities.MethodsData were taken from the International Social Survey Programme (ISSP), an annually repeated cross-sectional survey based on nationally representative samples. 23 countries (N = 37,228) were included and assigned to six welfare states. Attitude towards income-related health care inequalities was assessed by asking: “Is it fair or unfair that people with higher incomes can afford better health care than people with lower incomes?” with response categories ranging from “very fair” (1) to “very unfair” (5). On the individual level, sociodemographic (gender, age), socioeconomic (income, education) health-related (self-rated health), and health care factors (health insurance coverage, financial barriers to health care) were introduced.ResultsAbout two-thirds of the respondents in all countries think that it is unfair when people with higher incomes can afford better health care than people with lower incomes. Percentages vary between 42.8 in Taiwan and 84 in Slovenia. In terms of welfare states, this proportion is higher in Conservative, South European, and East European regimes than in East Asian, Liberal, and Social-Democratic regimes. Multilevel logistic regression analyses show that women, people affected by a low socioeconomic status, poor health, insufficient insurance coverage, and foregone care are more likely to perceive income-related health care inequalities as unfair.ConclusionsIn most countries a majority of the population perceives income-related health care inequalities as unfair. Large differences between countries were observed. Welfare regime classification is important for explaining the variation across countries.

The impact of care on family and health-related quality of life of parents with chronically ill and disabled children

Abstract Purpose: Parents of disabled and/or chronically ill children are more vulnerable regarding their health compared to parents of healthy children. This study examines how far the burden of care is associated with health-related quality of life (QoL) in parents, across different illnesses and disabilities. Moreover, it is unclear whether and to which extent familial resources can explain the association between parents’ care burden and health. Method: Data stem from a survey with the German Children’s Network, a self-help umbrella organization of parents and families of chronically ill and disabled children. Data collection was conducted nationwide with a standardized online questionnaire, which included children’s diagnoses and severity, burden of care, family and socioeconomic status, health-related QoL (SF-12) and family impact (Impact on Family Scale, IFS). 1567 parents participated. Results: A higher burden of care is associated with higher risks for poor health-related QoL. Especially, social impact and financial burden, which are both associated with care, can help to explain these associations. Conclusions: Future interventions should focus not only on the affected child but also on the whole family system and its social integration, as this seems likely to relief parents from burden of care. Therefore, a sustainable cooperation of health care institutions and professionals with self-help groups and parental initiatives is recommended. Implications for Rehabilitation Parents of disabled and chronically ill children are a vulnerable group regarding their health-related quality of life. A higher burden of care is associated with less social contacts, higher financial burden and higher help-needs in the household, which significantly contribute to higher health risks. Rehabilitation should take these constraints into account and put a stronger focus on the family of disabled and chronically ill children to support their inclusion. A sustainable and formally anchored collaboration with self-help and patient groups is recommended.

Income, financial barriers to health care and public health expenditure: A multilevel analysis of 28 countries

International studies have repeatedly shown that people with lower income are more likely to experience difficulties to access medical services. Less is known on why these relations vary across countries. This study investigates whether the association between income and financial barriers to health care is influenced by national public health expenditures (PHE, in % of total health expenditure). Data from the International Social Survey Programme (2011) was used (28 countries, 23,669 respondents). Financial barriers were assessed by the individual experience of forgone care due to financial reasons. Monthly equivalent household income was included as the main predictor. Other individual-level control variables were age, gender, education, subjective health, insurance coverage and place of living. PHE was considered as a macro-level predictor, adjusted for total health expenditure. Statistically significant associations between income and forgone care were found in 21 of 28 examined countries. Multilevel analyses across countries revealed that people with lower income have a higher likelihood to forgo needed medical care (OR: 3.94, 95%-CI: 2.96-5.24). After adjustments for individual-level covariates, this association slightly decreased (OR: 2.94, 95%-CI: 2.16-3.99). PHE did not moderate the relation between income and forgone care. The linkage between health system financing and inequalities in access to health care seems to be more complex than initially assumed, pointing towards further research to explore how PHE affects the redistribution of health resources in different health care systems.

Income and functional limitations among the aged in Europe: a trend analysis in 16 countries

Background Analyses are focused on 3 research questions: (1) Are there absolute and relative income-related inequalities in functional limitations among the aged in Europe? (2) Did the absolute and relative income-related inequalities in functional limitations among the aged change between 2002 and 2014? (3) Are there differences in the changes of income-related inequalities between European countries? Methods Data stem from 7 waves (2002–2014) of the European Social Survey. Samples of people aged 60 years or older from 16 European countries were analysed (N=63 024). Inequalities were measured by means of absolute prevalence rate differences and relative prevalence rate ratios of low versus high income. Meta-analyses with random-effect models were used to study the trends of inequalities in functional limitations over time. Results Functional limitations among people aged 60 years or older declined between 2002 and 2014 in most of the 16 European countries. Older people with a low income had higher rates of functional limitations and elevated rate ratios compared with people with high income. These inequalities were significant in many countries and were more pronounced among men than among women. Overall, absolute and relative income-related inequalities increased between 2002 and 2014, especially in Ireland, the Netherlands and Sweden. Conclusions High-income groups are more in favour of the observed overall decline in functional limitations than deprived groups. Results point to potential income-related inequalities in compression of morbidity in the recent past in Europe.

Gesundheitliche Ungleichheit im Alter@@@Health inequalities among the aged

The aim of this article is to provide an overview of the current state of research concerning health inequalities among the aged. First, health inequalities are introduced as a general phenomenon. Then, the magnitude of inequalities in elderly populations is described for different health indicators. In particular, analyses of the association between education and depressive symptoms based on a European dataset are presented. Subsequently, different hypotheses on age differences in health inequalities and possible explanations for social inequalities in health in elderly populations are discussed. Finally, some consequences for health policy, which can be derived from current research, are outlined.ZusammenfassungZiel des vorliegenden Beitrags ist es, einen Überblick über die aktuelle Forschungslage zum Thema gesundheitliche Ungleichheiten im höheren Lebensalter zu geben. Hierzu wird zunächst allgemein das Phänomen der gesundheitlichen Ungleichheit eingeführt. Darauf aufbauend wird das Ausmaß gesundheitlicher Ungleichheiten im höheren Lebensalter im Hinblick auf unterschiedliche Gesundheitsindikatoren beschrieben. Dabei werden auch eigene Analysen zum Zusammenhang von Bildung und depressiven Symptomen im Alter anhand eines europäischen Datensatzes präsentiert. Im darauf folgenden Abschnitt wird der Frage nachgegangen, inwieweit sich gesundheitliche Ungleichheiten mit zunehmendem Alter verändern. Anschließend wird auf mögliche Erklärungen für den Zusammenhang zwischen sozialer Ungleichheit und Gesundheit im höheren Lebensalter eingegangen. Zum Abschluss werden einige Schlussfolgerungen für die Gesundheitspolitik skizziert, die sich aus dem Stand der Forschung ableiten lassen.AbstractThe aim of this article is to provide an overview of the current state of research concerning health inequalities among the aged. First, health inequalities are introduced as a general phenomenon. Then, the magnitude of inequalities in elderly populations is described for different health indicators. In particular, analyses of the association between education and depressive symptoms based on a European dataset are presented. Subsequently, different hypotheses on age differences in health inequalities and possible explanations for social inequalities in health in elderly populations are discussed. Finally, some consequences for health policy, which can be derived from current research, are outlined.

Social relationships and GP use of middle-aged and older adults in Europe: a moderator analysis

Objectives This paper investigates (1) how social relationships (SRs) relate to the frequency of general practitioner (GP) visits among middle-aged and older adults in Europe, (2) if SRs moderate the association between self-rated health and GP visits, and (3) how the associations vary regarding employment status. Methods Data stem from the Survey of Health, Ageing and Retirement in Europe project (wave 4, 56 989 respondents, 50 years or older). GP use was assessed by frequency of contacts with GPs in the last 12 months. Predictors were self-rated health and structural (Social Integration Index (SII), social contact frequency) and functional (emotional closeness) aspects of SR. Regressions were used to measure the associations between GP use and those predictors. Sociodemographic and socioeconomic factors were used as covariates. Additional models were computed with interactions. Results Analyses did not reveal significant associations of functional and structural aspects of SR with frequency of GP visits (SII: incidence rate ratio (IRR)=0.99, 95% CI 0.97 to 1.01, social contact frequency: IRR=1.04, 95% CI 1.00 to 1.07, emotional closeness: IRR=1.02, 95% CI 1.00 to 1.04). Moderator analyses showed that ‘high social contact frequency people’ with better health had more statistically significant GP visits than ‘low social contact frequency people’ with better health. Furthermore, people with poor health and an emotionally close network showed a significantly higher number of GP visits compared with people with same health, but less close networks. Three-way interaction analyses indicated employment status specific behavioural patterns with regard to SR and GP use, but coefficients were mostly not significant. All in all, the not employed groups showed a higher number of GP visits. Conclusions Different indicators of SR showed statistically insignificantly associations with GP visits. Consequently, the relevance of SR may be rated rather low in quantitative terms for investigating GP use behaviour of middle-aged and older adults in Europe. Nevertheless, investigating the two-way and three-way interactions indicated potential inequalities in GP use due to different characteristics of SR accounting for health and employment status.