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Self-rated health (SRH) is an independent predictor of mortality; studies have investigated correlates of SRH to explain this predictive capability. However, the interplay of a broad array of factors that influence health status may not be adequately captured with parametric multivariate regression. This study investigated associations between several health determinants and SRH using recursive partitioning methods. This non-parametric analytic approach aimed to reflect the social-ecological model of health, emphasizing relationships between multiple health determinants, including biological, behavioral, and from social/physical environments. The study sample of 3648 men and women was drawn from the year 15 (2000–2001) data collection of the CARDIA Study, USA, in order to study a young adult sample. Classification tree analysis identified 15 distinct, mutually exclusive, subgroups (eight with a larger proportion of individuals with higher SRH, and seven with a larger proportion of lower SRH), and multi-domain risk and protective factors associated with subgroup membership. Health determinant profiles were not uniform between subgroups, even for those with similar health status. The subgroup with the largest proportion of higher SRH was characterized by several protective factors, whilst that with the largest proportion of lower SRH, with several negative risk factors; certain factors were associated with both higher and lower SRH subgroups. In the full sample, physical activity, education and income were highest ranked by variable importance (random forests analysis) in association with SRH. This exploratory study demonstrates the utility of recursive partitioning methods in studying the joint impact of multiple health determinants. The findings indicate that factors do not affect SRH in the same way across the whole sample. Multiple factors from different domains, and with varying relative importance, are associated with SRH in different subgroups. This has implications for developing and prioritizing appropriate interventions to target conditions and factors that improve self-rated health status., Highlights • Self-rated health (SRH) is an independent predictor of morbidity and mortality. • Partitioning identified 15 distinct subgroups by SRH status and multidomain factors. • Differing risk factor profiles have implications for strategies to improve SRH. • Physical activity, education, income ranked highest overall in relation to SRH. • This approach reflects a social-ecological perspective on correlates of SRH.

BackgroundLow control and high demand in the places where people work has been shown to partially explain why those in lower socioeconomic positions experience poorer health than their counterparts in higher socioeconomic positions. It would seem likely then that experiences of control in the wider living environment, beyond people’s places of work, might also play a role in shaping these health inequalities. Our recent review of theory revealed potential pathways by which low control in the living environment might explain the social patterning of health via low control beliefs and low actual control.MethodsBased on the potential pathways identified in our review of theory, we conducted a systematic review of longitudinal studies on the relationship between low control in the living environment and social inequalities in health published by January 2019, in English.ResultsSix studies were included in the review. Taken together, they provide evidence that lower social positions are associated with lower control beliefs and poorer health outcomes, in terms of heart disease, anxiety, depression and self-rated health, and that some of the association between low social position and health outcomes is explained by low control beliefs. No studies investigated the pathway from low actual control to poorer health in more disadvantaged groups.ConclusionThere is strong evidence from a small number of high-quality longitudinal studies that low perceived control in the living environment may play an important role in the pathways leading from low social position to poorer health and well-being. Further studies are needed to distinguish between the effects of having low control beliefs and having actual low control.

We conducted a systematic review of observational evidence on the health impacts of women's low control/autonomy in the living environment in societies with profound gender discrimination and gender bias. Thirty observational studies of varying methodological quality were included. Overall, the evidence suggests that women's lower control or autonomy (for example lack of freedom of movement outside the home, lack of authority to access healthcare for sick children) was associated with poorer mental and physical health for women and higher morbidity and mortality for their children, after adjusting for their socioeconomic circumstances. Further studies are needed to disentangle and understand the pathways between low control and health outcomes in contexts of profound gender discrimination. This systematic review has highlighted the general low quality of the evidence base on this research question. It identifies the pressing need for high quality, longitudinal studies in the future.

Recent years have seen a change in focus in UK public health policies towards an emphasis on individual lifestyle choices. As part of this shift, NHS health trainers were introduced in disadvantaged communities in England, to provide peer support to people ‘at risk’ of developing lifestyle-related health problems and to help them to self manage their behaviour. Concerns have been expressed, however, about the strength of the evidence supporting the initiative. This article outlines a number of gaps between the theory and rhetoric underpinning the NHS health trainer initiative, and the reality in practice. This article critiques the evaluation evidence, questions the assumption that engaging lay people in health promotion activities in place of health professionals is necessarily a preferable option, identifies inconsistencies in the evidence supporting individually based health improvement initiatives, and suggests that interventions which target deprived areas but neglect the social determinants of healt...

We conducted the first synthesis of theories on causal associations and pathways connecting degree of control in the living environment to socio-economic inequalities in health-related outcomes. We identified the main theories about how differences in ‘control over destiny’ could lead to socio-economic inequalities in health, and conceptualised these at three distinct explanatory levels: micro/personal; meso/community; and macro/societal. These levels are interrelated but have rarely been considered together in the disparate literatures in which they are located. This synthesis of theories provides new conceptual frameworks to contribute to the design and conduct of theory-led evaluations of actions to tackle inequalities in health.

Background Scientific debate has considered whether ‘control over destiny’ could be a fundamental social determinant of health (and a lack thereof, an underlying cause of health inequalities). We identified plausible theoretical pathways from control in the living environment to health inequalities at the micro-, meso- and macro-levels, and conducted a systematic review of the empirical evidence for these hypothesised pathways. Results for the micro-level are presented here. Methods Studies were identified by searching seven bibliographic databases, screening …

Background There is a growing public policy focus on empowerment for individuals and communities, and a belief that this may also reduce health inequalities. Our theory-driven systematic review of observational evidence on pathways between control and health revealed that low female control/empowerment was associated with adverse health outcomes and reduced survival for girls and women. We conducted a systematic review to address the question: what is the impact on health-related outcomes of interventions to improve the level of control in the living environment, differentiated by socio-economic status, gender, or ethnicity? Findings on women’s microfinance initiatives are presented here. Methods Studies were identified by searching seven bibliographic databases, screening reference lists, consulting key informants and searching organisational websites. All types of experimental and quasi-experimental study designs addressing the review question were included. Two reviewers carried out screening, data extraction and quality appraisal; disagreements were resolved through discussion with the wider team. Narrative synthesis of study findings drew upon conceptual frameworks developed in our previous review of pathways and the levels (micro/meso/macro) at which interventions might operate. Results From 17,361 initial records we identified 10 studies (one cluster-randomised control trial and 9 quasi-experimental studies) that met our inclusion criteria and evaluated the impact of microfinance initiatives. The interventions operated at the meso/community-level, via women’s empowerment, whilst also seeking to influence the macro/societal-level by raising the status of women. All were from low-to-middle income countries and targeted poor rural women. Nine of the 10 studies provided evidence of associations between participation in microfinance schemes and improvements in health-related outcomes (reduction in interpersonal violence against women and infant and child mortality, and increases in use of family planning methods and health services) when compared with non-participation. One study found a higher probability of women ever experiencing interpersonal violence among participants compared to non-participants. Conclusion Results from the microfinance studies reveal the potential health impact of attempts to influence control in the living environment by this type of intervention; providing rare evidence of a reduction in gender and socio-economic inequalities in health by purposeful theory-based programmes. More than 5 million poor rural women in Bangladesh alone are involved in such programmes. As the renewed focus on microfinance schemes grows in the UK and across the world, there is a need to learn from these evaluations. Future intervention studies should employ a robust research design to examine control/empowerment outcomes as well as differential impacts on health and wellbeing.

Background Recent public health strategies aim to increase the control, or power, that individuals, communities and populations have over decisions that affect their daily lives. While systematic reviews have revealed the health impact of measures to improve control in the work environment, evidence from the ‘living environment’ has not been synthesised. We conducted a critical review of proposed theories and causal pathways linking control in the living environment and socio-economic inequalities in health. Methods We identified theoretical discourses (published in books, academic papers, reports and policy documents) across a range of diverse fields, including: public health, social determinants of health and health inequalities; sociology/political science; and international development. Initially, seminal works were identified by experts. We then employed a ‘pearl-growing’ approach: hand-searching reference lists and asking key informants to identify additional publications. Theoretical elements were extracted and analytical frameworks developed to elucidate the pathways identified. Results On reviewing a substantial body of literature, we found the relationship between control in the living environment and health inequalities had been conceptualised at three levels: Personal level Low perceived control impacts on health via fatalism and hostility reactions, which are engendered by social position and the cumulative effects of chronic stress across the lifecourse. Micro/Meso level The immediate external environment, determined by social position, dictates opportunities for individuals and communities to exercise autonomy and control over their living conditions. This effect occurs at the individual, household and community levels, and is important for health via control beliefs (as above), people’s abilities to improve their living conditions and avoid disease risks, and through community trust and reciprocity. Macro level Socio-political structures and processes operate at the level of whole societies, stratifying access to resources and opportunities, or power, that people have to achieve good health. This can result in better health outcomes for low-income populations with greater gender equity; and negative outcomes for whole societies in which people lose the opportunity for control over their lives. Conclusion Theories proposed on how control in the living environment could lead to the generation of socio-economic inequalities in mental and physical health reveal a range of processes at individual, micro/meso and macro levels. The findings of this critical review are being used to inform a theory-led systematic review of empirical evidence examining the links between control and health. This will allow us to refine the conceptual pathways, and identify potential intervention points and promising interventions.