Social determinants of self-reported health in women and men: understanding the role of gender in population health

Background

Women and men share similar health challenges yet women report poorer health. The study investigates the social determinants of self-reported health in women and men, and male-female differences in health.

Methods

Data on 103154 men and 125728 women were analysed from 57 countries in the World Health Survey 2002–2004. Item Response Theory was used to construct a composite measure of health. Associations between health and determinants were assessed using multivariate linear regression. Blinder-Oaxaca decomposition partitioned the inequality in health between women and men into an “explained" component that arises because men and women differ in social and economic characteristics, and an “unexplained" component due to the differential effects of these characteristics. Decomposition was repeated for 18 countries in the World Health Organization (WHO) African region and 19 countries in the WHO European region.

Results

Women''s health was significantly lower than men''s. Health was associated with education, household economic status, employment, and marital status after controlling for age. In the pooled analysis decomposition showed that 30% of the inequality was “explained", of which almost 75% came from employment, education, marital status. The differential effects of being in paid employment increased the inequality. When countries in Africa and Europe were compared, the “explained" component (31% and 39% respectively) was largely attributed to the social determinants in the African countries and to women''s longevity in the European countries. Being in paid employment had a greater positive effect on the health of males in both regions.

Conclusions

Ways in which age and the social determinants contribute to the poorer health status of women compared with men varies between groups of countries. This study highlights the need for action to address social structures, institutional discrimination and harmful gender norms and roles that differently influence health with ageing.     

Association between clinical and subjective indicators of oral health status in an older adult population

Since the mid–1970s a number of investigators have developed measures of the extent to which oral disorders compromise functional, social and psychological well-being. They have also examined the associations between clinical indicators of oral health status and these subjective indicators. In general, these associations have been inconsistent and weak. One reason for this might be that the subjective indicators employed were rudimentary and insensitive to the health outcomes of oral disorders. The development of the Oral Health Impact Profile, a more sophisticated measure of the health outcomes of oral disorders, provided a method to examine this hypothesis. Using data from an oral health survey of older adults, we examined the associations between OHIP scores and a variety of clinical indicators of tooth loss, caries and periodontal disease. Even with this measure the associations were predominantly weak, the strongest of the correlations being 0.53. We also examined the influence of personal and sociodemographic characteristics on the relationship between tooth loss and its psychosocial outcomes. Five variables reflecting expectations and resources explained as much variance in OHIP scores as did the number of missing teeth. This analysis illustrates the essential distinction between disease and health and the way in which measures of oral health can be used to pursue fundamental issues in behavioural science and health services research.     

Two pathways, but how much do they diverge?

This document presents an argument on how low income differences are associated to the well being of the population. The health of the population was said to be related to either narrow differences in individual income or the greater effect of social disparity. The reality of the health benefits or the central policy implications could not be modified by the pathway. An experiment conducted on monkeys revealed that low status is a risk factor for poor health in a plausible psychosocial pathway. The income of the individual can be considered as one of the marker for social status and inequality in the society can be caused by material risk factors. Inequality effect of the small proportion of the population may be too great when explained using a curvature. Also, the income and health status in the developed countries is closely related and would still fall on the better part of the international curve. A less democratic society may develop an aggressive and less supportive social environment could cause deprivation and low social status. An increase in health inequalities was driven by a more socially antagonistic, delinquent and risky forms of behavior accompanied by deprivation throughout the society. The reduction of health inequalities associated between the pathways of income inequality and population health must not differ with the aim of improving health standards in the society. As a result, redistribution of health services could probably increase the health of those who are in need.     

Patterns of dental caries and treatment experience in elderly Lithuanians

Objective: The aim of the study was to evaluate patterns of caries experience in a representative sample of Lithuanians, aged 65‐74. Methods: This cross‐sectional study included 301 participants (response rate 54%). Information was obtained from a clinical examination (caries experience, stimulated salivary flow rates and oral hygiene levels) and a questionnaire. The questionnaire comprised questions about oral, general, physical, mental and social health and about background, knowledge, attitudes and lifestyle. The study had a multidimensional approach to negative consequences of disease and positive aspects of health. For bivariate testing, t‐test, ANOVA and Spearman's correlation were used. Factor analysis was combined with linear multiple regression for a multivariate study of caries experience patterns. Results: Elderly Lithuanians were found to have lower levels of edentulousness (range 11‐15%) than elderly people in other European countries. The mean number of missing teeth was also lower than in any of the neighbouring countries. A comparison of dentate and edentulous groups did not show any major differences. Those who reported that they had general disease had higher levels of oral health maintenance. In dentate elderly, caries experience differed according to place of residence, fluoride content in the drinking water, socio‐economic status, gender, lifestyle, and many other factors. The multivariate approach explained 52%. 61% and 55% of the variation in the number of filled or sound teeth (FS‐T), delayed (DT) and missing teeth (MT) respectively. Conclusion: Levels of oral health maintenance and caries experience show substantial variation among elderly Lithuanians, according to many health‐related characteristics. These elderly people require appropriate oral care, just as much as people in other population sub‐groups.     

Distribution and Numbers of Pygmies in Central African Forests

Pygmy populations occupy a vast territory extending west-to-east along the central African belt from the Congo Basin to Lake Victoria. However, their numbers and actual distribution is not known precisely. Here, we undertake this task by using locational data and population sizes for an unprecedented number of known Pygmy camps and settlements (n = 654) in five of the nine countries where currently distributed. With these data we develop spatial distribution models based on the favourability function, which distinguish areas with favourable environmental conditions from those less suitable for Pygmy presence. Highly favourable areas were significantly explained by presence of tropical forests, and by lower human pressure variables. For documented Pygmy settlements, we use the relationship between observed population sizes and predicted favourability values to estimate the total Pygmy population throughout Central Africa. We estimate that around 920,000 Pygmies (over 60% in DRC) is possible within favourable forest areas in Central Africa. We argue that fragmentation of the existing Pygmy populations, alongside pressure from extractive industries and sometimes conflict with conservation areas, endanger their future. There is an urgent need to inform policies that can mitigate against future external threats to these indigenous peoples’ culture and lifestyles.     

Dental Status of New Caledonian Children: Is There a Need for a New Oral Health Promotion Programme?

Background

Before implementing a new oral health promotion program in the French overseas territory of Nouvelle Calédonie, the health authorities needed recent data about dental status of the New Caledonian child population.

Objectives

This study aimed to describe the dental status of 6, 9 and 12-yr-old New Caledonian children and to investigate the environmental and behavioural risk factors related to oral health.

Methods

A randomly selected sample of 2734 children (744 6-yr-olds, 789 9-yr-olds, and 1201 12-yr-olds) was examined clinically by seven calibrated investigators and participants responded to a questionnaire. The main variables were objective criteria about dental status and subjective criteria about experience of dental care, dental fear, self-perception of oral health, cultural or ethnic identity and environmental and behavioural risk factors.

Results

Overall, most of the children had infectious oral diseases: more than 50% had gingivitis, and 60% of 6- and 9 yr-olds had at least one deciduous or permanent tooth with untreated caries. The mean 12-yr-old number of decayed missing and filled teeth (DMFT) was 2.09±2.82. The number of carious lesions was related to the unfavourable lifestyle, deprived social status and no preventive dental care. Kanak, Polynesians and Caledonians (respectively 27%, 18% and 45% of the study sample) were more affected by caries than metropolitan French and Asian children. Children with many untreated carious lesions had negative perceptions of their oral health; they complained of chewing difficulty and had higher scores for dental anxiety.

Conclusion

This study highlights the need for new strategies aimed at improving oral health and at reducing inequalities in New Caledonia. An oral health promotion program would need to be developed in connection with other health programmes using the common risk factor approach within the context of the local environment.     

Mirror-image responses in pygmy marmosets (Cebuella pygmaea)

Only a few nonhuman species (chimpanzees and orangutans) have displayed mirror-image recognition of themselves by grooming at a spot that can only be seen with the mirror. Pygmy marmosets have never been observed to self-groom, but they do behave toward mirrors in a manner suggestive of the early stages of mirror-image recognition. They displayed a rapid extinction of social threat responses to their own image and of novelty responses to mirrors, but continued to show mirror-specific responses such as following their own image, playing peek-a-boo, and looking at their image throughout a 28-day period of mirror exposure. The pygmy marmosets used a mirror to locate otherwise unseen conspecifics from other groups and directed threat responses toward the real location of these animals rather than to their mirror-image. Pygmy marmosets displayed the precursor behaviors to mirror-image recognition.     

'Inadequate' dietary habits and mastication in elderly men

Objective: The aim of this study was to re‐evaluate data about oral status, mastication and nutrition in elderly men in Malmö, Sweden, recorded in 1985–1987, to assess associations between inadequate dietary habits, oral conditions and masticatory function. Materials and methods: Four hundred and eighty‐one men, aged 67–68, participated in a comprehensive health examination, including tooth and denture status and masticatory tests. A separate study of dietary habits and nutritional status was made. Ninety‐five men had inadequate dietary habits. The databases of dental/denture status, mastication, nutritional status and social network factors were re‐evaluated for assessment of associations. Results: No significant differences between those with adequate or inadequate nutrition were found with regard to the number of teeth, occlusal contacts or removable dentures. Also self‐assessed chewing did not show any differences. Conclusion: Inadequate dietary habits were independent of teeth and denture status. Some correlations to social network conditions could be identified. Overweight, obesity, low physical activity and high alcohol intake were more common among those with inadequate nutritional intake.     

Indirect evidence for the genetic determination of short stature in African Pygmies

Central African Pygmy populations are known to be the shortest human populations worldwide. Many evolutionary hypotheses have been proposed to explain this short stature: adaptation to food limitations, climate, forest density, or high mortality rates. However, such hypotheses are difficult to test given the lack of long-term surveys and demographic data. Whether the short stature observed nowadays in African Pygmy populations as compared to their Non-Pygmy neighbors is determined by genetic factors remains widely unknown. Here, we study a uniquely large new anthropometrical dataset comprising more than 1,000 individuals from 10 Central African Pygmy and neighboring Non-Pygmy populations, categorized as such based on cultural criteria rather than height. We show that climate, or forest density may not play a major role in the difference in adult stature between existing Pygmies and Non-Pygmies, without ruling out the hypothesis that such factors played an important evolutionary role in the past. Furthermore, we analyzed the relationship between stature and neutral genetic variation in a subset of 213 individuals and found that the Pygmy individuals' stature was significantly positively correlated with levels of genetic similarity with the Non-Pygmy gene-pool for both men and women. Overall, we show that a Pygmy individual exhibiting a high level of genetic admixture with the neighboring Non-Pygmies is likely to be taller. These results show for the first time that the major morphological difference in stature found between Central African Pygmy and Non-Pygmy populations is likely determined by genetic factors.     

Health and social inequality in Europe.

In most European countries health has been shown to be linked to social circumstances--gradients in health status have persisted for decades, despite major changes in the principal causes of death. In central and eastern Europe life expectancy has stagnated since the mid-60s, whereas in the West it has increased; but even in the West it is related to income distribution. Social differences in mortality in men are three times as large in some countries as in others, and are influenced by factors other than conventional risk factors. Substantial declines in mortality and morbidity could result from a narrowing of health inequalities even when differences in health risk between social groups are comparatively small. Policies to reduce health inequalities can be introduced in smaller communities and organisations such as the school and workplace. National policies are variable; factors generating inequalities require action across several policy areas.     

Multi-species monitoring of rare wetland fishes should account for imperfect detection of sampling devices

Accuracy in estimating occupancy of a threatened species is important for conservation but false absences bias many monitoring programs. Imperfect detection is especially relevant to surveys of rare wetland fishes which are often small-bodied and cryptic. Many factors influence probability of detection, including fish size and abundance, habitat characteristics and sampling devices. Imperfect detection can be addressed by accounting for probability of detection when estimating occupancy by modelling detection/non-detection data collected in replicate surveys. Three ecological specialists were once common in habitats associated with Lake Alexandrina at the terminus of the Murray–Darling Basin, Australia. The threatened Murray Hardyhead (Craterocephalus fluviatilis), Southern Pygmy Perch (Nannoperca australis) and Yarra Pygmy Perch (N. obscura) are now rare in the region following population collapses during a prolonged drought, and ongoing monitoring aims to assess their statuses for management purposes. This study compares probability of detection of the rare wetland fishes and cohabiting species during 2 years of multi-species monitoring using contrasting sampling devices (fyke and seine). The findings suggest large variations in estimated probability of detection can occur between devices for Murray Hardyhead and Southern Pygmy Perch. Yarra Pygmy Perch was undetected during the study. Overall, the findings show multi-species monitoring programs using a single sampling device may wrongly estimate the occupancy of a target fish. By accounting for imperfect detection, multi-species monitoring programs will improve inferences regarding population status, recovery and habitat quality of fishes to more accurately inform wetland management.     

Plumage variability, status signalling and individual recognition in avian flocks

A decade ago it was suggested that much of the plumage variability exhibited by flocking birds can be explained by 'status signalling', plumage variability being used to signal agonistic status(1). As a result of this suggestion, a number of studies have examined the social significance of plumage differences, but the status signalling hypothesis has not received unequivocal support. Other factors, such as the facilitation of individual recognition, also appear to be important in explaining plumage variability.     

Perceptions of medical school stressors: their relationship to age, year of study and trait anxiety

It has been noted that medical school is a stressful social environment. This study proposes to determine domains of medical school stressors and to investigate to what extent the perceived stressfulness of these domains is explained by age, year of study, marital status, sex, and trait anxiety. Data were obtained by self-administered questionnaires filled out by 131 students in four classes of a six-year medical school. Four clusters of stressors were revealed by factor analysis: "off-time death," "incurable condition," "patient contact," and "medical practice demands." Marital status, sex, and year of study did not correlate with any of these stressor domains. Age was positively correlated with the perception of off-time death as stressful and negatively correlated with patient contact. Trait anxiety was directly correlated with the perceived stressfulness of patient contact and medical practice demands. No independent variable explained differences in perception of all four domains. It is suggested that there are some experiences, such as facing off-time death, that are so painful that repeated exposure to them augments, rather than decreases, the perception of their stressfulness.     

How Do People Attribute Income-Related Inequalities in Health? A Cross-Sectional Study in Ontario,Canada

Context

Substantive equity-focused policy changes in Ontario, Canada have yet to be realized and may be limited by a lack of widespread public support. An understanding of how the public attributes inequalities can be informative for developing widespread support. Therefore, the objectives of this study were to examine how Ontarians attribute income-related health inequalities.

Methods

We conducted a telephone survey of 2,006 Ontarians using random digit dialing. The survey included thirteen questions relevant to the theme of attributions of income-related health inequalities, with each statement linked to a known social determinant of health. The statements were further categorized depending on whether the statement was framed around blaming the poor for health inequalities, the plight of the poor as a cause of health inequalities, or the privilege of the rich as a cause of health inequalities.

Results

There was high agreement for statements that attributed inequalities to differences between the rich and the poor in terms of employment, social status, income and food security, and conversely, the least agreement for statements that attributed inequalities to differences in terms of early childhood development, social exclusion, the social gradient and personal health practices and coping skills. Mean agreement was lower for the two statements that suggested blame for income-related health inequalities lies with the poor (43.1%) than for the three statements that attributed inequalities to the plight of the poor (58.3%) or the eight statements that attributed inequalities to the privilege of the rich (58.7%).

Discussion

A majority of this sample of Ontarians were willing to attribute inequalities to the social determinants of health, and were willing to accept messages that framed inequalities around the privilege of the rich or the plight of the poor. These findings will inform education campaigns, campaigns aimed at increasing public support for equity-focused public policy, and knowledge translation strategies.     

Oral health awareness in Croatian and Italian urban adolescents

Purpose of this study was to investigate and compare differences in oral health awareness between Croatian and Italian urban adolescents. The sample consisted of primary school last grade students aged between 13 and 15 years, 300 children from Zagreb (Croatia) and 298 children from Bari (Italy). Oral health awareness was evaluated using a self-administered standardized questionnaire. Self-perception of oral health proved to be different between the two groups (p < 0.001). The Croatians reported that their oral health was "excellent" or "very-good" more often than the Italians (68.6% vs. 50.2%). The reasons given for visiting a dentist were different (p < 0.001). The Italians cleaned their teeth more often than the Croatians ("two or more times a day", 83.1% vs. 72.2%, p < 0.003). Wooden toothpicks were preferred by the Croatians (p < 0.001), while floss was preferred by the Italians (p = 0.03). The awareness regarding the use of fluoridated toothpaste was higher in the Italian group (95.6% vs. 72.5%, p < 0.001). The Croatians were consuming sweetened foods more often than the Italians (p < 0.001). Croatian adolescents reported more indicators of a lower level of oral health awareness than the Italians, while on the contrary Croatians had higher esteem of their oral health. Defining national preventive strategies is essential for improving adolescents' attitudes toward oral health in both countries, particularly in Croatia.     

Educational Inequalities in Exit from Paid Employment among Dutch Workers: The Influence of Health,Lifestyle and Work

Background

Individuals with lower socioeconomic status are at increased risk of involuntary exit from paid employment. To give sound advice for primary prevention in the workforce, insight is needed into the role of mediating factors between socioeconomic status and labour force participation. Therefore, it is aimed to investigate the influence of health status, lifestyle-related factors and work characteristics on educational differences in exit from paid employment.

Methods

14,708 Dutch employees participated in a ten-year follow-up study during 1999–2008. At baseline, education, self-perceived health, lifestyle (smoking, alcohol, sports, BMI) and psychosocial (demands, control, rewards) and physical work characteristics were measured by questionnaire. Employment status was ascertained monthly based on tax records. The relation between education, health, lifestyle, work-characteristics and exit from paid employment through disability benefits, unemployment, early retirement and economic inactivity was investigated by competing risks regression analyses. The mediating effects of these factors on educational differences in exit from paid employment were tested using a stepwise approach.

Results

Lower educated workers were more likely to exit paid employment through disability benefits (SHR:1.84), unemployment (SHR:1.74), and economic inactivity (SHR:1.53) but not due to early retirement (SHR:0.92). Poor or moderate health, an unhealthy lifestyle, and unfavourable work characteristics were associated with disability benefits and unemployment, and an unhealthy lifestyle with economic inactivity. Educational differences in disability benefits were explained for 40% by health, 31% by lifestyle, and 12% by work characteristics. For economic inactivity and unemployment, up to 14% and 21% of the educational differences could be explained, particularly by lifestyle-related factors.

Conclusions

There are educational differences in exit from paid employment, which are partly mediated by health, lifestyle and work characteristics, particularly for disability benefits. Health promotion and improving working conditions seem important measures to maintain a productive workforce, particularly among workers with a low education.     

(Un)Healthy in the City: Respiratory,Cardiometabolic and Mental Health Associated with Urbanity

Background

Research has shown that health differences exist between urban and rural areas. Most studies conducted, however, have focused on single health outcomes and have not assessed to what extent the association of urbanity with health is explained by population composition or socioeconomic status of the area. Our aim is to investigate associations of urbanity with four different health outcomes (i.e. lung function, metabolic syndrome, depression and anxiety) and to assess whether these associations are independent of residents’ characteristics and area socioeconomic status.

Methods

Our study population consisted of 74,733 individuals (42% males, mean age 43.8) who were part of the baseline sample of the LifeLines Cohort Study. Health outcomes were objectively measured with spirometry, a physical examination, laboratory blood analyses, and a psychiatric interview. Using multilevel linear and logistic regression models, associations of urbanity with lung function, and prevalence of metabolic syndrome, major depressive disorder and generalized anxiety disorder were assessed. All models were sequentially adjusted for age, sex, highest education, household equivalent income, smoking, physical activity, and mean neighborhood income.

Results

As compared with individuals living in rural areas, those in semi-urban or urban areas had a poorer lung function (β -1.62, 95% CI -2.07;-1.16), and higher prevalence of major depressive disorder (OR 1.65, 95% CI 1.35;2.00), and generalized anxiety disorder (OR 1.58, 95% CI 1.35;1.84). Prevalence of metabolic syndrome, however, was lower in urban areas (OR 0.51, 95% CI 0.44;0.59). These associations were only partly explained by differences in residents’ demographic, socioeconomic and lifestyle characteristics and socioeconomic status of the areas.

Conclusions

Our results suggest a differential health impact of urbanity according to type of disease. Living in an urban environment appears to be beneficial for cardiometabolic health but to have a detrimental impact on respiratory function and mental health. Future research should investigate which underlying mechanisms explain the differential health impact of urbanity.     

Relationship between subjective assessment of oral health and medical expenses in community-dwelling elderly persons

doi: 10.1111/j.1741‐2358.2011.00459.x
Relationship between subjective assessment of oral health and medical expenses in community‐dwelling elderly persons Objectives: The increasing medical expenses of elderly persons in Japan’s rapidly ageing society have become a major concern. It is therefore important to elucidate the factors associated with such escalation. Here, we focused on the relationship between subjective self‐assessment of oral health, as an index of general health, and medical expenses (excluding dental repair) under the hypothesis that oral health contributes to general medical expenses. Several studies have shown that oral health status is correlated with general health status among elderly persons. We speculated that oral health status might show a relation with medical costs among elderly persons. However, few studies have investigated this relationship to date. Materials and Methods: Participants were 259 elderly subjects (range: 65–84 years; 120 men, 139 women) residing independently. Subjective assessment of oral health was evaluated by their responses (‘Good’, ‘Not good’ and ‘Not at all good’) on a survey questionnaire. The correlation between subjective assessment of oral health and medical expenditure was analysed using Spearman’s rank method, the Mann–Whitney U‐test and the Kruskal–Wallis test. Medical expenses were used as the dependent variable in multinomial logistic regression analysis with background and intraoral factors as independent variables. Results: A slight yet statistically significant correlation was observed between subjective assessment of oral health and outpatient treatment fees. Conclusion: The findings revealed that subjective assessment of oral health is significantly and independently related to the medical expenses of community‐dwelling elderly persons after adjusting for social background, living environment and physical factors.     

Ethnic background,social class or status? Developments in school attainment of the children of immigrants in The Netherlands

In the field of education and children of immigrants we are confronted with a peculiar clash of opinions. Some believe that the differences in school attainment between indigenous children and children of immigrant families can be explained in terms of social class. Others seek the differences in terms of status groups. Empirical research was carried out in one of the bigger cities of The Netherlands, which attempted to further this theoretical debate. The results indicate that the influence of an immigrant background on school attainment is largely mediated by both social class and status. Ethnicity, however, also has a specific effect on education, independent of social class and status. It is argued that the characteristic of ethnicity is a sociological kind of motivation. The educational motivation of immigrant families can have a ‘positive’ effect in the sense that ‘black’ schools perform reasonably well, and a ‘negative’ effect in the sense that immigrant children at schools with a high level of aspiration perform less well than their indigenous Dutch schoolmates.