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Residential segregation is the spatial manifestation of entrenched socioeconomic and racial inequities and is considered a fundamental cause of racial inequalities in health. Despite the well-documented racialized spatial inequalities that exist in urban areas throughout Brazil, few empirical investigations have examined the link between residential segregation and health and considered its implications for racial health inequalities in this setting. In the present study, we used data from the Brazilian Longitudinal Study of Adult Health (2008e2010) to examine the association between economic residential segregation and two major cardio-metabolic risk factorsdhypertension and diabetes. We also examined whether associations were stronger for historically marginalized racial groups in Brazil. Residential segregation was calculated for study-defined neighborhoods using the Getis-Ord Local Gi* statistic and was based on household income data from the 2010 IBGE demographic census. Multivariable logistic regression models were used to examine associations. In our sample, Blacks and Browns were more likely to live in economically segregated neighborhoods. After taking into account income, education, and other demographic characteristics we found that individuals living in the most economically segregated neighborhoods were 26% more likely to have hypertension and 50% more likely to have diabetes than individuals living in more affluent areas. Although Blacks and Browns living in highly segregated neighborhoods had higher prevalence of hypertension and diabetes compared to Whites, we observed no statistically significant racial differences in the associations with residential segregation. Our findings suggest that residential segregation may be an important structural determinant of cardio-metabolic risk factors in Brazil. Moreover, the systematic and disproportionate exposure of Blacks and Browns to highly segregated neighborhoods may implicate these settings as potential drivers of racial inequalities in cardio-metabolic risk factors in urban settings in Brazil.

Structural racism has been linked to racial health inequalities and may operate through an unequal labor market that results in inequalities in psychosocial workplace environments (PWE). Experiences of the PWE may be a critical but understudied source of racial health disparities as most adults spend a large portion of their lives in the workplace, and work-related stress affects health outcomes. Further, it is not clear if the objective characteristics of the workplace are important for health inequalities or if these inequalities are driven by the perception of the workplace. Using data from the 2008 to 2012 waves of the Health and Retirement Study (HRS), a probability-based sample of US adults 50 years of age and older and the Department of Labor’s Occupational Information Network (O*NET), we examine the role of both standardized, objective (O*NET) and survey-based, subjective (as in HRS) measures of PWEs on health and Black-White health inequalities. We find that Blacks experience more stressful PWEs and have poorer health as measured by self-rated health, episodic memory function, and mean arterial pressure. Mediation analyses suggest that these objective O*NET ratings, but not the subjective perceptions, partially explain the relationship between race and health. We discuss these results within the extant literature on workplace and health and health inequalities. Furthermore, we discuss the use of standardized objective measures of the PWE to capture racial inequalities in workplace environment.

The concept of intersectionality has been used to analyze and understand how multiple forms of identity and oppression interact to shape life experiences of marginalized groups. We conducted a qualitative study to explore how Black Brazilian women experience the intersections of race, class, and gender and the ways in which these intersecting experiences act as social determinants of health. Nine focus groups were conducted with Black, White, and mixed-race women of childbearing age (n = 37), social and health activists (n = 11), and health professionals (n = 20). The focus groups took place in two cities in the Brazilian state of Bahia during October and November 2012. Using a comparative approach, we describe participants' responses regarding the life experiences of women of differing racial and class backgrounds. Our findings highlight how the intersectional relationship between race, class, and gender alters women's social context and life course opportunities, as well as their stressors and protective buffers. We argue that the differing intersectional experiences of women due to race and class create unique social contexts that define the parameters of health and wellness. In addition, we argue that the experiences at each intersection (i.e., raceXclass, raceXgender, classXgender, raceXclassXgender) have a unique character that can be qualitatively described. Improved specification of exposures experienced by marginalized populations who experience intersecting forms of oppression can help explain intra- and inter-group differences in health outcomes, and may also lead to improved intervention models.

Despite the widespread use of self-rated health (SRH) in population health studies, the meaning of this holistic health judgment remains an open question. Gender differences in health, an issue of utmost importance in population research and policy, are often measured with SRH; the comparisons could be biased if men and women differ in how they form their health judgment. The aim of this study is to examine whether men and women differ in how health inputs predict their health rating across the adult life span. We use the 2002-2015 National Health Interview Survey data from US-born respondents aged 25-84. Ordered logistic models of SRH as a function of 24 health measures including medical conditions and symptoms, mental health, functioning, health care utilization, and health behaviors, all interacted with gender, test how the measures influence health ratings and the extent to which these influences differ by gender. Using a Bayesian approach, we then compare how closely a select health measure (K6 score) corresponds to SRH levels among men and women. We find little systematic gender difference in the structure of SRH: men and women use wide-ranging health-related frames of reference in a similar way when making health judgments, with some exceptions: mid-life and older men weigh physical functioning deficits and negative health behaviors more heavily than women. Women report worse SRH than men on average but this only holds through mid-adulthood and is reversed at older ages; moreover, the female disadvantage disappears when differences in socio-economic and health covariates are considered. Our findings suggest that the meaning of SRH is similar for women and men. Both groups use a broad range of health-related information in forming their health judgment. This conclusion strengthens the validity of SRH in measuring gender differences in health.

Rationale Despite theoretical work suggesting that health behaviors should be considered in tandem rather than as individual and disconnected practices, little quantitative work has examined different lifestyles of health behavior practices. In addition, while a significant body of work has examined the association of holding multiple social roles and health outcomes, little work has examined how acquiring multiple roles in early adulthood influences health behavior. Objective This article (a) illustrates the utility of examining health lifestyles—defined as constellations of individual health behavior practices—and (b) contributes to the literature on how accumulating multiple social roles is associated with health. Methods Using two waves of the National Longitudinal Study of Adolescent to Adult Health (N = 12,098) a structural equation modeling approach is used to both (a) model latent health lifestyles from observed health behavior indicators, and (b) to predict health lifestyle membership based on changes in role-occupancy during the transition to early adulthood. Results Results suggest that the type of social role matters, with intensive obligatory roles associated with lifestyles of less tobacco, alcohol, and marijuana use but also with physical inactivity. In contrast, voluntary roles are associated with more active lifestyles but increased alcohol use. Conclusion The results illustrate the importance of modeling overall health lifestyles rather than focusing only on individual health behaviors. The results also advance our understanding of how holding multiple roles is associated with health by extending the framework to an examination of health behavior.

Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.

Existing research has found a positive association between countries’ level of democratic governance and the health of their populations, although that research is limited by the use of data from small numbers of high-income countries or aggregate data that do not assess individual-level health outcomes. We extend prior research by using multilevel World Health Survey (2002-2004) data on 313,554 individuals in 67 countries, and find that the positive association between democratic governance and self-rated health persists after adjusting for both individual- and country-level confounders. However, the mechanisms linking democracy and self-rated health remain unclear. Individual-level measures of socioeconomic status, and country-level measures of economic inequality and investments in public health and education, do not significantly mediate the association between democratic governance and self-rated health. The persistent association between democratic governance and health suggests that the political organization of societies may be an important upstream determinant of population health.

Health disparities are increasingly studied in and across a growing array of societies. While novel contexts and comparisons are a promising development, this commentary highlights four challenges to finding appropriate and adequate health measures when making comparisons across groups within a society or across distinctive societies. These challenges affect the accuracy with which we characterize the degree of inequality, limiting possibilities for effectively targeting resources to improve health and reduce disparities. First, comparisons may be challenged by different distributions of disease and second, by variation in the availability and quality of vital events and census data often used to measure health. Third, the comparability of self-reported information about specific health conditions may vary across social groups or societies because of diagnosis bias or diagnosis avoidance. Fourth, self-reported overall health measures or measures of specific symptoms may not be comparable across groups if they use different reference groups or interpret questions or concepts differently. We explain specific issues that make up each type of challenge and show how they may lead to underestimates or inflation of estimated health disparities. We also discuss approaches that have been used to address them in prior research, note where further innovation is needed to solve lingering problems, and make recommendations for improving future research. Many of our examples are drawn from South Africa or the United States, societies characterized by substantial socioeconomic inequality across ethnic groups and wide disparities in many health outcomes, but the issues explored throughout apply to a wide variety of contexts and inquiries.

This article draws upon a major social science theoretical approach-systemic racism theory-to assess decades of empirical research on racial dimensions of U.S. health care and public health institutions. From the 1600s, the oppression of Americans of color has been systemic and rationalized using a white racial framing-with its constituent racist stereotypes, ideologies, images, narratives, and emotions. We review historical literature on racially exploitative medical and public health practices that helped generate and sustain this racial framing and related structural discrimination targeting Americans of color. We examine contemporary research on racial differentials in medical practices, white clinicians' racial framing, and views of patients and physicians of color to demonstrate the continuing reality of systemic racism throughout health care and public health institutions. We conclude from research that institutionalized white socioeconomic resources, discrimination, and racialized framing from centuries of slavery, segregation, and contemporary white oppression severely limit and restrict access of many Americans of color to adequate socioeconomic resources-and to adequate health care and health outcomes. Dealing justly with continuing racial "disparities" in health and health care requires a conceptual paradigm that realistically assesses U.S. society's white-racist roots and contemporary racist realities. We conclude briefly with examples of successful public policies that have brought structural changes in racial and class differentials in health care and public health in the U.S. and other countries.

Racial and ethnic disparities in mental health care access in the United States are well documented. Prior studies highlight the importance of individual and community factors such as health insurance coverage, language and cultural barriers, and socioeconomic differences, though these factors fail to explain the extent of measured disparities. A critical factor in mental health care access is a local area’s organization and supply of mental health care providers. However, it is unclear how geographic differences in provider organization and supply impact racial/ethnic disparities. The present study is the first analysis of a nationally representative U.S. sample to identify contextual factors (county-level provider organization and supply, as well as socioeconomic characteristics) associated with use of mental health care services and how these factors differ across racial/ethnic groups. Hierarchical logistic models were used to examine racial/ethnic differences in the association of county-level provider organization (health maintenance organization (HMO) penetration) and supply (density of specialty mental health providers and existence of a community mental health center) with any use of mental health services and specialty mental health services. Models controlled for individual- and county-level socio-demographic and mental health characteristics. Increased county-level supply of mental health care providers was significantly associated with greater use of any mental health services and any specialty care, and these positive associations were greater for Latinos and African-Americans compared to non-Latino Whites. Expanding the mental health care workforce holds promise for reducing racial/ethnic disparities in mental health care access. Policymakers should consider that increasing the management of mental health care may not only decrease expenditures, but also provide a potential lever for reducing mental health care disparities between social groups.

A robust socioeconomic gradient in health is well-documented, with higher socioeconomic status (SES) associated with better health across the SES spectrum. However, recent studies of U.S. racial/ethnic minorities and immigrants show complex SES-health patterns (e.g., flat gradients), with individuals of low SES having similar or better health than their richer, U.S.-born and more acculturated counterparts, a so-called “epidemiological paradox” or “immigrant health paradox”. To examine whether this exists among Asian Americans, we investigate how nativity and occupational class (white-collar, blue-collar, service, unemployed) are associated with subjective health (self-rated physical health, self-rated mental health) and 12-month DSM-IV mental disorders (any mental disorder, anxiety, depression). We analyzed data from 1530 Asian respondents to the 2002–2003 National Latino and Asian American Study in the labor force using hierarchical multivariate logistic regression models controlling for confounders, subjective social status (SSS), material and psychosocial factors theorized to explain health inequalities. Compared to U.S.-born Asians, immigrants had worse socioeconomic profiles, and controlling for age and gender, increased odds for reporting fair/poor mental health and decreased odds for any DSM-IV mental disorder and anxiety. No strong occupational class-health gradients were found. The foreign-born health-protective effect persisted after controlling for SSS but became nonsignificant after controlling for material and psychosocial factors. Speaking fair/poor English was strongly associated with all outcomes. Material and psychosocial factors were associated with some outcomes – perceived financial need with subjective health, uninsurance with self-rated mental health and depression, social support, discrimination and acculturative stress with all or most DSM-IV outcomes. Our findings caution against using terms like “immigrant health paradox” which oversimplify complex patterns and mask negative outcomes among underserved sub-groups (e.g., speaking fair/poor English, experiencing acculturative stress). We discuss implications for better measurement of SES and health given the absence of a gradient and seemingly contradictory finding of nativity-related differences in self-rated health and DSM-IV mental disorders.

Structural theories of stratification predict that groups with low positions in social hierarchies experience high rates of mental health problems. Extensions of this approach such as a triple jeopardy hypotheses claim that groups that are subordinate in multiple stratification systems such as gender, race and class are at especially high risk. Multiple minority statuses affect mental health in paradoxical ways, however, that refute triple jeopardy approaches. This paper presents a theoretical perspective based in cultural as well as structural theories that offers an alternative to triple jeopardy. I predict that certain relational schemas are jointly shaped by gender, race, and class and help explain their anomalous effects on mental health. These schemas of self-salience refer to beliefs about the relative importance of the self and others in social relations; they affect mental health by forming subjective alternative hierarchies to larger societal stratification systems. I use secondary analyses of two U.S. data sets to investigate this perspective. Results of regression analysis show that self-salience helps explain the paradoxical patterns of mental health by gender, race, and social class. The findings underscore the importance of using an intersectional approach and integrating cultural and structural factors to understand how stratification shapes mental health.

This paper assesses how the relationship between health and educational attainment has changed over the last three decades. We examine trends in disease prevalence and self-reported health using the US National Health Interview Survey for five chronic conditions-arthritis, diabetes, heart disease, hypertension, and lung diseases. The sample is limited to non-Hispanic Whites ages 40-64 to focus on the value of education and not changing representation of minority populations. We find that health benefits associated with additional schooling rose over time by more than ten percentage points as measured by self-reported health status. This can be attributed to both a growing disparity by education in the probability of having major chronic diseases during middle age, and better health outcomes for those with each disease. The value of education in achieving better health has increased over the last 25 years; both in protecting against onset of disease and promoting better health outcomes amongst those with a disease. Besides better access to health insurance, the more educated increasingly adapted better health behaviors, particularly not smoking and engaging in vigorous exercise, and reaped the benefits of improving medical technology. Rising health disparities by education are an important social concern which may require targeted interventions.

Despite extensive research on the relationship between social capital and health, the specific pathways through which social capital is related to health have not been fully elucidated. Moreover, research has generally been cross-sectional, particularly in Canada, and hence not clearly attentive to the causal relationship between social capital and health. In this study we have examined the importance of multiple forms of individual social capital for the functional health status of adult Canadians, employing the Canadian National Population Health Survey (NPHS). We examine changes in health between 1996 and 2000, using individual level variables from 1996 as predictors. In our final model, the key aspect of social capital affecting changes in health status is being loved by someone. This is predicted by being married, frequency of family contacts, religious service attendance and being born in Canada. Insecurity about food also has a direct effect on changes in health status. The latter is affected by income, daily smoking and age. The results suggest that policies to support family stability and family unification, for example through immigration, and efforts to minimize the disruptions of divorce could contribute to the health of Canadians.

Numerous studies document improvements in health status and health expectancies among older adults over time. However, most evidence is from developed nations and gender differences in health trends are often inconsistent. It remains unknown whether changes in health in developing countries resemble Western trends or whether patterns of health improvement are unique to the country's epidemiologic transition and gender norms. Using two nationally representative samples of non-institutionalized adults in China aged 65 years and older, this study investigates gender differences in the improvements in disability, chronic disease prevalence, and self-rated health from 1992 to 2002. Results from multivariate logistic regression models show that all three indicators of health improved over the 10-year period, with the largest improvement in self-rated health. With the exception of disability, the health of women improved more than men. Using Sullivan's decomposition methods, we also show that active life expectancy, disease-free life expectancy, and healthy life expectancy increased over this decade and were patterned differently according to gender. Overall, the findings demonstrate that China experienced broad health improvements during its early stages of the epidemiologic transition and that these changes were not uniform by gender. We discuss the public health implications of the findings in the context of China's rapidly aging population.

The emerging fields of social epidemiology and population health seek to understand the social determinants of health. Especially, with regards to how income inequality causes health disparities, attention has been focused on material and psychosocial mechanisms. I use examples from the epidemiological and social science literature to argue for a third broad etiological framework: the role played by the ways we generally recognize, define, name, and categorize disease states and attribute them to a cause or set of causes. These framing effects shape population health by influencing: health and illness beliefs; patterns of consumption and other behaviors; perceptions of what interventions and policies work; class, ethnic, and other social dynamics; and clinical and public health practices. Important characteristics of many framing phenomena are their capacity to be self-perpetuating and their performative power. A better understanding of framing effects can lead to deploying them more deliberatively and flexibly to improve individual and population health.

Several recent studies in the US, Canada, and the UK have demonstrated a positive relationship between family income and child health, though the mechanisms underlying this relationship are poorly understood. Using data from the 1988 US National Maternal and Infant Health Survey and the 1991 follow-up, this paper tests whether maternal health status and health behaviors during pregnancy and early infancy can explain the relationship between family income and subjective health status at age 3. We find that, while a detailed set of controls for health risk factors including maternal smoking, drinking, and vitamin use during pregnancy, as well as breastfeeding and secondhand smoke exposure after birth, are significantly related to family income and maternal education, they do not explain the relationship between family income and maternal-assessed health of the child. We suggest that these results point to either more salient pathways through which family income impacts child health, such as maternal stress, or to the possibility that differences in subjective health status do not correspond to differences in objective health status in the same way for higher- and lower-income respondents.

The relationship between poverty and mental health has received considerable attention in the recent literature. However, the associations presented in existing studies typically rely on limited samples of individuals and on proxy indicators for poverty such as education, the lack of tap water, or being unemployed. We revisit the relationship between poverty and mental health using data from nationally representative household surveys in Bosnia and Herzegovina, Indonesia and Mexico, along with special surveys from India and Tonga. As in previous studies, we find that individuals who are older, female, widowed, and in poor health are more likely to report worse mental health outcomes. Individuals living with others with poor mental health are significantly more likely to report worse mental health themselves. The size of the coefficients and their significance are comparable across the five countries. In contrast to previous studies, the relationship between higher education and better mental health is weak or non-existent. Furthermore, there is no consistent association between consumption poverty and mental health - in two countries mental health measures are marginally worse for the poor; in two countries there is no association; and in one country mental health measures are better for the poor compared to the non-poor. Moreover, the sizes of the coefficients for both education and consumption poverty are small compared to other factors considered here. While the lack of an association between consumption poverty and mental health implies that poor mental health is not a "disease of affluence", neither is it a disease of poverty. Changes in life circumstances brought on, for instance, by illness may have a greater impact on mental health than levels of poverty. Effective public health policy for mental health should focus on protecting individuals and households from adverse events and on targeted interventions following such adverse changes.

The debate over the role of race/ethnicity in determining disease susceptibility has re-emerged since it was declared that race was arbitrary biological fiction more than 50 years ago. Partly due to advancements in the Human Genome Project and related technologies, the idea that race/ethnicity does have a genetic basis is enjoying a resurgence. A rise in the use of race in genetic studies has left many researchers who are committed to a social conceptualization of race at a loss regarding how to evaluate these developments. The commentary attempts to correct the problem by providing a critical review of the state of research on race, genetics and health. This review aims to bring social health disparities researchers up-to-date on developments in the genetic literature and to facilitate a more critical engagement of research that purports to find a genetic basis to racial disparities in health.

Gender differences in adult health are well documented, but only recently has research begun to investigate how race and ethnicity condition gendered health disparities. This paper contributes to this line of inquiry by assessing gender differences in morbidity across five major US racial and ethnic populations. Using data from the 1997-2001 waves of the National Health Interview Survey, the analysis examines differences in men and women's self-rated health, functional limitations, and life-threatening medical conditions for whites, blacks, Mexicans, Puerto Ricans, and Cubans. For each health outcome, we investigate the utility of socioeconomic factors in accounting for observed disparities. Contrary to finding universal excess in female morbidity, the results show that the magnitude of gender difference varies considerably by racial/ethnic group, health outcome, and comparison category. The most striking findings are the consistently higher levels of functional limitations for all women compared to men in their same racial/ethnic group and the poorer health of black women relative to both white and black men for all health measures, after adjustment for socioeconomic and background factors. The gender gap for all other health measures is more variable, and for Mexican women a difference is only evident for functional limitations and only when compared to Mexican men. Our results underscore the need for more research on the role of race and ethnicity in shaping gendered health inequalities and the mechanisms that lead to such variable patterns of difference across and within US racial and ethnic populations.

The purpose of this research is to document and explain ethnic variation in health among Latino adults in the United States. Results of analyses of data pooled from the 1997–2001 National Health Interview surveys reveal that health patterns are clearly different among Latino ethnic groups. Mexicans have health advantages, whereas Puerto Ricans experience health disparities. Cubans and Dominicans reveal a mix of health disparities and advantages, depending on the health outcome. The effects of social determinants of health are also contingent upon ethnicity. For example, worse health is associated with higher levels of socioeconomic status (SES) and acculturation among Mexicans, but with lower levels of SES and acculturation among Latinos whose origins are from Caribbean islands. We conclude that racial/ethnic comparative health research should avoid pan-ethnic groupings, and explicitly acknowledge ethnic group distinctiveness.

Set within the determinants of health framework and drawing upon Statistics Canada's longitudinal National Population Health Survey, this paper explores the self-assessed health of Canada's immigrant population. Using both descriptive and multivariate techniques, including logistic regression and survival analysis, the intent is to identify differences in self-assessed health between the immigrant and native-born populations, the factors that contribute to immigrant self-assessed health, and the factors associated with declining self-assessed health status. In each case, the key questions are whether differences in health status exist between the native- and foreign-born. Results indicate mixed support for the Healthy Immigrant Effect, with the native- and foreign-born neither more nor less likely to rank their health as fair or poor. However, results from the proportional hazards model indicated that the native-born were at lower risk to transition to poor health.

This paper investigates the effect of health selection and its contribution to the social class gradient in health. Both inter- and intra-generational mobility were examined. Longitudinal data on health and social class at three life stages (16, 23, 33 years) are from the 1958 British birth cohort. Individuals with poor health were more likely to move down and less likely to move up the social scale, especially at the inter-generational transition. The effect of health selection on the social gradient was variable, of modest size and cannot be regarded as a major explanation for inequalities in health in early adulthood.

Given the framework of the 1984 Canada Health Act, the health status of immigrants should be similar to average levels within whole of Canada. Yet, assuming equality of health status between immigrant and non-immigrants, or between immigrant groups is likely an unrealistic and simplistic assumption, given unseen barriers affecting accessibility, the restructuring of the Canadian health care system, and problems with the provision of health care resources to the immigrant population. Using the National Population Health Survey, this paper focuses upon the health status of the immigrant population relative to that of non-immigrants within Canada, with reference to diagnosed conditions, self-assessed health, and the Health Utilities Index Mark 3. Findings indicate that, with the exception of the most recent arrivals, immigrants experience worse health status across most dimensions relative to non-immigrants. Multivariate analysis reveals that age, income adequacy, gender, and home ownership are dimensions upon which health status differs between the two groups.

There is a growing literature on an overall direct relationship between health and social position in developed countries. The relationship, however, is less well documented in developing countries where social hierarchies are changing more rapidly, demographic and health transitions are less advanced, and this topic has received less attention from researchers than in some developed countries. This paper presents an empirical investigation of the relationship between social stratification and social development and population health using data on over 6000 adults from the National Health Survey of Pakistan, a nationally representative health examination survey of people in that country. We analyze four indicators of poor nutrition in adults from this data set. The findings reveal complex relationships among social development, social stratification and the consequences for the health of the people of Pakistan. Underweight is related to economic status, anemia to education and social development, and both severe dental caries and a monotonous diet are related to both development and economic status which interact with each other. These results suggest that continued conceptual refinement and the development of standardized measures of stratification and development would contribute to building cross-nationally comparable data sets addressing issues of the relationship among health and economic development and health transitions.

Studies have documented that health and income are important variables affecting the quality of life in old age. However, there is little knowledge about whether perceived financial sufficiency affects the health of elderly persons. Recent research has documented that in addition to material and behavioural determinants, psychosocial pathways also have an influence on health inequalities. This is the first paper to examine the relation between self-rated economic condition (measured with a single item question) and reported health conditions (i.e., somatic complaints, diagnosed physical diseases, functional health (Activities of Daily Living), self-rated health, and mental health status (General Health Questionnaire-30 [GHQ-30]) among elderly persons in Hong Kong. The respondents of the study were persons aged 65 and over residing in public housing estates in the Southern District of Hong Kong Island. Four hundred and fifty respondents were interviewed in 1995 by means of a structured questionnaire. The study found that although it did not record the actual income levels of the respondents, the subjective measure vividly demonstrated the health differentials among the elderly respondents. Multiple regression analyses suggested that self-rated economic condition was a significant predictor of the number of somatic complaints and physical illnesses reported, as well as of functional health, self-rated health, and mental health status (controlling for socio-demographic variables). However, the measure explained a higher proportion of variance in models related to psychological health than those related to physical health. The findings substantiated the role of psychosocial processes in understanding perceived health and illness and health inequalities in particular.

Since 1989 Poland has been experiencing large-scale social and economic changes as a result of the reforms associated with the transition to a market economy. This study uses a 1996 Health Survey of over 20,000 women to examine the impact of the new socio-economic situation and of women's multiple roles on their health at the early stage of transition. We investigated the importance of selected economic, socio-demographic and cultural determinants in explaining differences in women's health status in Poland, focusing on education level, (un)employment, living conditions, marital status, smoking and life style. There are health inequalities between men and women in Poland based on life expectancy, chronic diseases and health self-assessment. Some of these, especially the large differences between life expectancy at working ages, may be attributed to the difficult socio-economic situation. The multivariate analysis of women's self-assessed health and morbidity from selected chronic diseases indicated substantial inequalities in health. Together with the behavioural and cultural risk factors recognized by medicine, such as obesity, lack of physical exercise and smoking, the paper shows the crucial role of economic factors in influencing Polish women's health. Women whose financial position is poor are more likely to assess their health as less than good, to suffer from respiratory and circulatory systems' diseases and report neurotic problems. Other factors, strongly connected with the transition process in Poland, which contribute to health problems are lack of employment and low educational level, particularly for younger women. Women's marital and parental status are also important predictors of some categories of health problems; however, their influence varies for women of different ages. Our survey also supports the thesis that loneliness in old age, defined on the basis of living in a one-person household, may be negatively correlated with health status.

This study defines vulnerability as a multi-dimensional construct, reflected in the convergence of predisposing, enabling, and need attributes of risk. Using race, income, and self-perceived health status as indicators and based on eight rounds of the US 1996 panel of the Medical Expenditure Panel Survey, the study examined how the interactions of these vulnerable characteristics affect insurance coverage, a critical measure of health care access. The results of the study demonstrate insurance coverage does vary with the extent of vulnerability. While race and income significantly influence insurance coverage, respectively, there was relatively little disparity in insurance due to health status. Between race and income, income was a more significant predictor of lack of insurance coverage since low-income people regardless of race and health were significantly more likely to be uninsured or partially insured. However, it is important to note that minorities were disproportionately over-represented in the low-income or bad health groups so that any adverse association between income, bad health, and insurance status would affect minorities significantly more than whites. Among those with insurance, the most vulnerable group, the minority-low-income-bad health group or those with all the three vulnerability indicators, were most likely to be publicly insured. A policy implication is to target limited resources on insurance coverage for the more vulnerable groups, those with a convergence or cluster of predisposing, enabling, and need attributes of risk.

The Final Report of the World Health Organization (WHO) Commission on the Social Determinants of Health is a substantial and important contribution to understanding the social factors that shape global health inequities. Although gender is highlighted as a key social determinant of health, the report's conceptual approach inappropriately equates gender and health with women's health. This essay discusses the analytic and policy implications of this shortcoming.

International and national research has documented the relations between socio-economic conditions and health. Nonetheless, racial/ethnic group comparisons of health indices frequently are presented in the United States without stratifying or adjusting for socio-economic conditions that could affect interpretation of the data. This paper examines how racial/ethnic group identifiers have been used in past research. While some studies assume biologic differences; others presume that race/ethnicity is a proxy for socio-economic race factors. One consequence of these presumptions has been an underdevelopment of knowledge about racial/ethnic minority populations that could help shape public policies and preventive interventions to reduce disparities in health. Findings from studies that examine the influence of both race and social class on health are reviewed in an effort to clarify the state-of-knowledge. Although the findings vary for particular health indices, the studies provide considerable evidence that socio-economic conditions are a powerful, although not necessarily exclusive, explanatory variable for racial disparities in health. The findings are used as the basis for encouraging more theoretically grounded and methodologically rigorous research rather than avoiding an assessment of the influence of race/ethnicity on health.

Both poverty and other factors associated with race are related to child health. However, the mechanisms of these relationships have not been adequately specified. The purpose of this study was to explore the relationship of the social environment to child health status in black and white children and further, to explore whether the patterns of the effects of social class were different by race. This study provides further evidence that the social environment is strongly associated with child health status. Several risk factors are similar for both white and black children: mothers who view their own health as fair or poor are much more likely to rate their children in poor health. The presence of childhood chronic medical conditions is independently associated with poor health status regardless of race. However, the relative importance of several social risks for poor health status differs between white and black children. Specifically, while low family income is a consistent risk factor for poor health among white children, low income alone is not a risk factor for black children. Among black children,other social risks that are associated with poverty, such as low maternal education and a mother's perception of her own health as poor, increased the risk for poorer health in the child.

This study explores mechanisms involved in self-evaluation of health by making specifications of linkages among various dimensions of health status, physiological measures, social and behavioral factors or characteristics. The proposed structural equation model is tested by using data from a comprehensive health survey of the population of Finnmark county, Norway (1987-88), including 4549 men and 4360 women aged 30-62. The findings suggest the burden of physical distress and reliance on permanent disablement benefit to play the key role in reducing self-evaluated health. The seemingly strong labelling impact of permanent work disability, contrasted the modest effect of diagnoses of chronic disease. Moreover, the impact of both these key factors and other important determinants is strongly socially patterned. Positive health related life-style appeared to have a positive impact on self-rated health, while preoccupation with health had a negative impact. This finding adds some credibility to the suggestion that the growing occupation and fascination with health have some negative health outcomes.

This paper described the present pattern of mortality, morbidity, invalidity, use of services, and life-style according to relevant social characteristics. On the whole, the empirical evidence shows that lower socioeconomic groups, identified either by level of education, profession, or region of residence, continue to score worse on different health measures despite a general improvement in their state of health. Two results are of particular importance. Some southern regions accumulated a higher concentration of ill-health conditions and became multi-problem areas. Middle and, above all, upper social groups have increasingly used the private health sector despite that fact that they are covered under the National Health Service provisions. This last development may be counter-productive for the strategy of equalization introduced in 1978 with the NHS.

Sweden is one of Europe's most egalitarian countries. The social inequities in living conditions have been gradually reduced to a level that is more equal than in most countries in Europe. Even if general health development has been positive during recent years, data reviewed here indicate that there may be adverse effects for some groups which may increase inequities. This article presents results on inequities in health from the Public Health Report of Sweden 1987 and discusses causal mechanisms and implications for health policy.

Levels of health development are formed by mathematically clustering countries using six health status indicators: crude birth, crude death, infant mortality and child death rates, and male and female life expectancy. Stratifying two international samples of 128 and 163 countries into levels of health development--groups with similar health status profiles--improves the results of regression analyses used to identify economic, political, social, educational, health and other health determinants. For this reason, health development levels are a systematic framework for delineation of health determinants. Earlier large scale statistical studies have been limited in their success in part because they did not partition their data sets prior to analysis, or used inappropriate criteria that blurred rather than heightened developmental differences in underlying social systems. These developmental differences regulate the way in which health status inputs are converted into health status outputs, defining the relative importance of health determinants at various developmental levels. At lowest health development levels (countries with poorer health status), the under-development of economic, health and educational infrastructures creates a vacuum which allows international intervention (aid, investment, export/import activities) to play a dominant role in health status determination. At middle health development levels, health and educational infrastructures are better developed, but still secondary in importance as health status determinants to basic economic infrastructure. Demographic problems are particularly apparent at these levels. At higher health development levels, education, women's status, and political structure are especially important health status determinants. This research has facilitated the identification of health status determinants for use in health policy analysis. Recommendations for future research include use of findings in health policymaking by individual countries and by comparative researchers, and development of appropriate health systems models for each level of health development.

Social inequalities related to health is described with reference to health services, children's health, and common health indicators for the adult population. On all descriptive dimensions it turns out that members of certain social groups are more ill-fated with regard to health and health services than are members of other groups. These results are discussed with reference to the relationship between social conditions and health, and with regard to the questions about what forms of knowledge on this relationship is needed in order to plan efforts to change the existing conditions. Important points that are made suggest that is more important to focus upon vulnerable groups than on social classes or socio-economic groups, and that most of the material available on the relationship between health indicators and social variables is too abstract for use in planning of effective health policies, that at the same time aim at improved health conditions in the population and more equity with regard to distribution of the health burdens.

A cross-sectional study of all Black and Caucasian enlisted males in the U.S. Navy between 1974 and 1979 was conducted to determine if there were any significant racial group differences in disease incidence. First hospitalization rates for sixteen ICDA-8 diagnostic categories and selected diagnoses were examined and compared on the basis of race, age, year hospitalized, education and occupation. Results indicated that total disease incidence among Black males has declined in the past decade, with a reduction in total first hospitalizations from 1652 per 10,000 men in 1974 to 1088 per 10,000 men in 1979. Total incidence rates for Caucasian males in the same period declined from 1347 per 10,000 men to 1100 per 10,000 men. However, Blacks were found to be at significant risk for: mental disorders; diseases of the genitourinary system; diseases of the circulatory system; diseases of the digestive system; diseases of the blood and blood-forming organs; symptoms and ill-defined conditions; supplementary classifications; and diseases of the musculoskeletal system. Caucasians had significant higher incidence rates for diseases of the skin and subcutaneous tissue, and accidents, poisonings and violence. Nevertheless, the study results indicated that the populations of Blacks and Caucasians in the Navy are not uniform with respect to disease incidence. There exist numerous subgroups within either racial group, defined on the basis of certain demographic and social characteristics, which are at risk for particular diseases. In addition, the relationship between race and disease is mediated by several factors, including genetic predisposition, socioeconomic status and cultural patterns of belief and behavior. No single factor can account for the excess risk for all diseases among all members of either racial group.

Self-care has been characterized as the basic level of health care in all societies. However, little is known about existing self-care behaviour. Although it is clear that laypersons do indeed routinely self-evaluate and self-treat many of their health problems as a part of daily living, the nature and extent of these self-care practices are not well understood. It is not clear whether self-care behaviour is equally prevalent among different social groups; whether self-care is used for both health maintenance and the treatment of illness; and whether self-care is used only in response to selected symptomatic conditions. More studies of general lay populations are needed to provide this type of information. Particularly, studies which recognize that laypersons are not only consumers of professional care, but are also primary providers and active participants in the health care process. The purpose of the present study was to identify the range of self-care practices used at this time by Canadians and to explore some of the correlates of this behaviour. Data were obtained in 1983 through personal interviews with a randomly selected cross-sectional sample of 524 residents of Winnipeg, Canada. The dimensions of self-care investigated were: symptomatic self-treatment responses; recent self-medication activity; and the use of home remedies. Potential correlates considered include: sociodemographics; perceived health status; understanding of medical knowledge; attitudes toward medical care; and health maintenance/lifestyle beliefs and internal preventive control beliefs. A correlational analysis was performed to test the nature and strength of the association between all of the variables measured. Next, stepwise multiple regression was used to identify the best set of predictors of each of the self-care behaviours and hierarchical regression was used to assess the amount of variance explained by subsets of the correlates (e.g. sociodemographics, beliefs, attitudes). The results suggest that selected social characteristics and skeptical attitudes toward doctors may be important correlates of self-care. However, in view of the diverse nature of self-care behaviour it seems unlikely that a single set of factors will be able to explain all forms of self-provided health care. The paper concludes with a discussion of personal and professional responsibility for health and implications for self-care research.

In Africa the literature specifically linking the state, class and the allocation of health resources is sparse, and the evidential base for health research is inadequate and difficult to interpret. This paper looks at some of the ways in which state, class and health may be related in southern Africa. The region provides useful comparisons because of the starkness of the relationships between class and race and disease patterns and health care in much of the sub-continent; the different types of state and class structure within southern Africa; and the changes in ideology and to some extent health practice which came with the political independence of some of its component parts. Using both historical and contemporary data, it pinpoints the importance of analysing the specific and changing form of the state in the different countries of the region, in order to understand the social determinants of disease and the allocation of health resources, and looks at the significance of class, race, ethnicity and gender in the incidence of health and the state's response. It highlights the specific colonial legacies, continuing imperial linkages and location of countries in the international division of labour which inhibit changes in health care. Within the region, the migrant labour system and South Africa's aggressive policies of destabilisation create particular problems for weak states and for individuals within them attempting to implement more progressive health care programmes. The paper also argues that the ideological role played by health care has to be understood, and shows the diverse uses to which it is put across the region. The paper concludes that while the position of the state in the international and regional economy, its specific form and the nature of its class relations are predictors in some sense of health and health care, a variety of micro-level political and social decisions and mediations have also to be taken into account. While most of the countries of the region are in some sense part of the 'periphery', and a product of colonialism, these labels are insufficient to explain the differences between them in terms of disease patterns and health care systems. The specificities of internal social dynamics, local class ethnic and gender struggles and political conflicts are also crucial.

The relationships between education/occupation/income and health status have been well documented in the international epidemiological and sociological literature for many years, however, specific studies on the subject are scarce in Canada. Even when relationships have been demonstrated, the reasons for these relationships are much debated. This study presents an analysis of the relationship between socioeconomic status (SES) and health status. The study is based on analysis of data from a sample of nearly 2000 male principal income earners from the 1978 Canada Health Survey. Firstly, is there a relationship between an individual's SES and health status in Canada? Secondly, what aspects of SES—education, occupational status, and/or income—are most important? Thirdly, what are the possible explanations of the observed relationship? That is, is it possible to disaggregate the relationship and thereby infer possible causal mechanisms? The findings indicated a direct positive relationship between SES and health status, i.e. the higher an individual's SES, the better that person's health. The major exception to this was the SES/fitness relationship. In this instance, the higher the SES, the lower the level of fitness. Though age was an important control variable as SES, fitness and illness are age related, the findings relating SES to the health measures remained even when age was controlled for. Of the three SES measures, income was consistently the best correlate of health status. Occupational status showed the most inconsistent relationships with health status. The findings supported both the social causation and social selection hypotheses. That is, social position can have an effect on health status (social causation), while health status can affect one's social position (social selection).