Paula Holland

Life course accumulation of disadvantage: childhood health and hazard exposure during adulthood.

The present paper examines the association between physical and social disadvantage during childhood and lifetime exposure to health-damaging environments. Study members were participants of Boyd Orrs clinical, social and dietary survey conducted between 1937 and 1939 and were aged between 5 and 14 years at clinical examination. Study participants were traced and between 1997 and 1998 a random sample of 294 were interviewed. The lifegrid interview method was used to collect full occupational, residential and household histories, from which accumulated lifetime exposures to a range of environmental hazards were estimated. Age-adjusted height during childhood was found to be inversely related to subsequent exposure to all hazards combined (males p = 0.002; females p = 0.001). This relationship was found in males with manual fathers (p = 0.044) and females with non-manual fathers (p = 0.035). Chronic disease during childhood was also associated with greater subsequent hazard exposure in males with manual fathers (p = 0.008). Among females with non-manual fathers, in contrast, chronic disease during childhood was associated with reduced subsequent hazard exposure (p = 0.05). These findings suggest that exposure to health-damaging environments during adulthood may accumulate on top of health disadvantage during childhood and that this process of life course accumulation of disadvantage may vary by gender and childhood social class.

Financial stress and strain associated with terminal cancer--a review of the evidence.

Financial circumstances are a significant influence on the quality of life for older people and may be important to health and wellbeing at the end of life. The aim of this study is to review the evidence for the existence and consequences of financial stress and strain at the end of life for people dying with cancer. We conducted a systematic search of four electronic databases for studies, providing data on illness-related financial burden (stress), or perception of financial hardship (strain), from patients with terminal cancer or their caregivers. Twenty-four papers were identified from 21 studies published in English between 1980 and 2006, the majority (14) of cross-sectional design. Financial stress was reported in all 13 studies from the USA (median 33%, range 10—66%), but only four sought measures of financial strain. In the USA, specific social consequences, such as moving house or change in employment to cope with caregiving, were reported in four of these studies; one of these also noted changes in treatment choices and avoidance of care for other family members. In studies from outside the USA, there is a dearth of data on financial stresses and the consequences of this for the household, despite widespread reporting of financial strain. To fill a gap in our understanding and improve holistic palliative care, researchers need to ask the questions about the consequences of financial stresses and strain for the health and wellbeing of the household. Palliative Medicine 2007; 21 : 595—607

The role of income differences in explaining social inequalities in self rated health in Sweden and Britain

STUDY OBJECTIVE To analyse to what extent differences in income, using two distinct measures—as distribution across quintiles and poverty—explain social inequalities in self rated health, for men and women, in Sweden and Britain. DESIGN Series of cross sectional surveys, the Swedish Survey of Living Conditions (ULF) and the British General Household Survey (GHS), during the period 1992–95. PARTICIPANTS AND SETTING Swedish and British men and women aged 25—64 years. Approximately 4000 Swedes and 12 500 Britons are interviewed each year in the cross sectional studies used. The sample contains 15 766 people in the Swedish dataset and 49 604 people in the British dataset. MAIN RESULTS The magnitude of social inequalities in less than good self rated health was similar in Sweden and in Britain, but adjusting for income differences explained a greater part of these in Britain than in Sweden. In Britain the distribution across income quintiles explained 47% of the social inequalities in self rated health among women and 31% among men, while in Sweden it explained, for women 13% and for men 20%. Poverty explained 22% for British women and 8% for British men of the social inequalities in self rated health, while in Sweden poverty explained much less (men 2.5% and women 0%). CONCLUSIONS The magnitude of social inequalities in self rated health was similar in Sweden and in Britain. However, the distribution of income across occupational social classes explains a larger part of these inequalities in Britain than in Sweden. One reason for this may be the differential exposure to low income and poverty in the two countries.

The social and economic consequences of childhood-onset Type 1 diabetes mellitus across the lifecourse: a systematic review

Background  The incidence of childhood‐onset (Type 1) diabetes is high, and increasing, particularly among the very young. The aim of this review was to determine the longer‐term social consequences of having diabetes as a child and to determine whether adverse consequences are more severe for disadvantaged children.

Winners and Losers in Flexible Labor Markets: The Fate of Women with Chronic Illness in Contrasting Policy Environments—Sweden and Britain:

This study compares employment rates among men and women with and without chronic illness in the contrasting policy environments of Britain and Sweden, through analysis of household surveys for 1979–1995. Professional and managerial groups were winners in both countries, including during recession. By the 1990s, employment rates for healthy Swedish women were uniformly high across the social groups and almost comparable with those of their male counterparts; rates for women and men with a chronic illness were also comparable, albeit at a lower overall rate. The greatest losers were male and female unskilled manual workers in Britain. British women with a chronic illness in the 1990s had less than half the employment rates of healthy women. Such social inequalities were much smaller and less consistent in Sweden, where the impact of illness was softened for all social groups. In Britain, workless men tended to be classed as unemployed or permanently sick, while workless women were more likely to be classed as looking after home/family. Lesser differences were seen in Sweden. No evidence was found to support the hypothesis that women in general, and the less skilled and sick in particular, would be the winners in a more flexible, less regulated labor market—quite the reverse.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part II: The impact of active and passive labor market policies.

The authors investigate three hypotheses on the influence of labor market deregulation, decommodification, and investment in active labor market policies on the employment of chronically ill and disabled people. The study explores the interaction between employment, chronic illness, and educational level for men and women in Canada, Denmark, Norway, Sweden, and the United Kingdom, countries with advanced social welfare systems and universal health care but with varying types of active and passive labor market policies. People with chronic illness were found to fare better in employment terms in the Nordic countries than in Canada or the United Kingdom. Their employment chances also varied by educational level and country. The employment impact of having both chronic illness and low education was not just additive but synergistic. This amplification was strongest for British men and women, Norwegian men, and Danish women. Hypotheses on the disincentive effects of tighter employment regulation or more generous welfare benefits were not supported. The hypothesis that greater investments in active labor market policies may improve the employment of chronically ill people was partially supported. Attention must be paid to the differential impact of macro-level policies on the labor market participation of chronically ill and disabled people with low education, a group facing multiple barriers to gaining employment.

Labor market participation following onset of seizures and early epilepsy: Findings from a UK cohort

Purpose:  Previous studies have reported a considerable employment disadvantage among people with epilepsy. In a cohort of men and women who had experienced a single seizure or had early epilepsy at study entry we explored employment status and social mobility over 4 years and investigated whether employment outcomes were more disadvantageous for certain social groups.

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes.

BackgroundStigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men’s health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men’s participation in and utilisation of HIV services in Uganda.MethodsInterviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.ResultsOur findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men’s participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men’s risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a ‘sick role’; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men’s involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.ConclusionTo improve men’s involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

Socioeconomic measures in early old age as indicators of previous lifetime exposure to environmental health hazards

The relationship between disadvantage in early old age and disadvantage earlier in life was investigated by collecting lifetime residential and occupational histories from 294 subjects aged between 63 and 78 years. Lifetime exposure scores, expressed as the age-adjusted number of years exposed to a range of health hazards, were calculated. Associations between these scores and six measures of socioeconomic position after retirement were examined. Compared with the more advantaged, the more disadvantaged on each post-retirement socioeconomic measure had higher lifetime exposure scores. Mutual adjustment showed that the Registrar Generals (RG) social class, based on the persons own last main occupation, had the strongest association with previous hazard exposure. In the absence of the information required to assign an RG class status, receipt of state welfare benefits in early old age had the strongest association with previous hazard exposure for women, whilst for men, current tenure status was most strongly associated.

Delayed and differential effects of the economic crisis in Sweden in the 1990s on health-related exclusion from the labour market:A health equity assessment

UNLABELLED Many OECD countries are currently experiencing economic crisis and introducing counter-measures with unknown effects. To learn from previous experience, we explored whether there were delayed or differential effects of the Swedish recession in the 1990s and the governments response to it for people with limiting longstanding illness or disability (LLSI) from different socioeconomic groups (SEGs), by policy analysis and secondary data analysis of the Swedish Survey of Living Conditions (ULF) from 1978 to 2005. The government policy response involved cutting public expenditure, privatising some services and measures to boost private sector employment. There was a decline in overall employment rates from the early 1990s, particularly among men and women with LLSI and in lower SEGs. Public sector employment declined from 53 to 40 percent among women and from 23 to 14 percent among men. Private sector employment increased modestly for women (from 31 percent to 37 percent), and stayed stable at 59-60 percent among men. Following economic recovery, employment rates continued to decline among men and women with LLSI from manual SEGs, while the employment levels increased among most healthy men and women. There was a concomitant increase in rates of LLSI, sickness absence and rates of disability pension particularly among women in lower SEGs. CONCLUSION The policy response to the 1990s economic crisis in Sweden had differential consequences, hitting the employment of women in the public sector, especially women with both LLSI and low socioeconomic status. The observed increase in disability pension rates, particularly among women with LLSI in lower SEGs, may be a delayed effect of the policy response to the economic crisis.