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Exploring trends in and determinants of educational inequalities in self-rated health
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Uppsala University, Sweden.
Vastmanland County Council, Sweden.
Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
Örebro County Council, Sweden.
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2015 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 43, no 7, p. 677-686Article in journal (Refereed) Published
Abstract [en]

Aims: Educational inequalities in self-rated health (SRH) in European welfare countries are documented, but recent trends in these inequalities are less well understood. We examined educational inequalities in SRH in different age groups, and the contribution of selected material, behavioural and psychosocial determinants from 2000 to 2008. Methods: Data were derived from cross-sectional surveys conducted in 2000, 2004 and 2008 including 37,478, 34,876 and 32,982 respondents, respectively, aged 25-75 in mid-Sweden. Inequalities were analysed by age-standardized and age-stratified rate ratios of poor SRH and age-standardized prevalence of determinants, and contribution of determinants by age-adjusted logistic regression. Results: Relative educational inequalities in SRH increased among women from 2000 (rate ratio (RR) 1.70, 95% CI 1.55-1.85) to 2008 (RR 2.07, 95% CI 1.90-2.26), but were unchanged among men (RR 1.91-2.01). The increase among women was mainly due to growing inequalities in the age group 25-34 years. In 2008, significant age differences emerged with larger inequalities in the youngest compared with the oldest age group in both genders. All determinants were more prevalent in low educational groups; the most prominent were lack of a financial buffer, smoking and low optimism. Educational differences were unchanged over the years for most determinants. In all three surveys, examined determinants together explained a substantial part of the educational inequalities in SRH. Conclusions: Increased relative educational health inequalities among women, and persisting inequalities among men, were paralleled by unchanged, large differences in material/structural, behavioural and psychosocial factors. Interventions to reduce these inequalities need to focus on early mid-life.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS LTD , 2015. Vol. 43, no 7, p. 677-686
Keywords [en]
Health status disparities; social medicine; socioeconomic factors; educational status
National Category
Public Health, Global Health and Social Medicine
Identifiers
URN: urn:nbn:se:liu:diva-122099DOI: 10.1177/1403494815592271ISI: 000361768900002PubMedID: 26138729OAI: oai:DiVA.org:liu-122099DiVA, id: diva2:861909
Note

Funding Agencies|Centre for Clinical Research Sormland, Uppsala University; Sormland County Council, Sweden; County Council of Vastmanland; County Council of Uppsala; County Council of Sormland; County Council of Orebro; County Council of Varmland

Available from: 2015-10-19 Created: 2015-10-19 Last updated: 2025-02-20
In thesis
1. Inequalities in Health: the Importance of Material/Structural Factors and Psychosocial Resources
Open this publication in new window or tab >>Inequalities in Health: the Importance of Material/Structural Factors and Psychosocial Resources
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Socioeconomic inequalities in health are well-documented in most countries. Health differences have been shown to follow a gradient, where health status in average is somewhat poorer for every lower level in the social hierarchy. Notably, the welfare state Sweden is no exception. Considerable socioeconomic inequalities in health are found, and the magnitude of e.g. educational inequalities in health has even increased over recent decades. Important contributors, or “health determinants” of observed health inequalities, include material/structural factors, behavioral factors and psychosocial factors. The inequalities arise from uneven distributions of these health determinants accumulated over the life course. Whereas earlier research has focused on independent effects of different determinants, recent research has showed that health determinants interact in complex ways when contributing to health inequalities. However, the relative importance of the independent contributions of specific types of health determinants and of the shared contributions have not been assessed. 

The overall aim of this thesis was to examine possible explanations of inequalities in self-reported health among groups with different educational levels in a Swedish population, in particular how material/structural factors and psychosocial resources contribute to these inequalities. 

This thesis is based on four population-based studies. Studies I and IV used data from the Life & health study, based on crosssectional survey questionnaires, conducted in 2000, 2004 and 2008 in five counties in the central part of Sweden. Around 35,000 respondents were included each year with response rates varying from 60% to 67%. Studies II and III used data from a sub-sample of the Swedish national public health survey (HLV) from 2012, another cross-sectional survey questionnaire. The sub-sample was carried out in four counties in the central part of Sweden. The total number of respondents in the sub-sample was 26,706, with a response rate of 53%. Outcome variables were, in studies I, II and IV, self-rated health (SRH) and, in study III, psychological distress. The magnitudes of health inequalities were examined using rate ratios and rate differences. The associations between health determinants and health out-comes were examined using logistic regression, and the analysis of independent versus shared contributions of health determinants to health inequalities was conducted using structural equation modeling (SEM). 

Study I showed that relative educational inequalities in SRH were two-fold among men, unchanged from 2000 to 2008, while the inequalities initially were smaller among women but increased over time, from 1.7 to 2.1. This increase was mainly due to growing inequalities in the age group 25–34 years. The distributions of all observed health determinants were more unfavorable in low education groups; most prominent for lack of a financial buffer, smoking and low optimism. These educational differences were, for most health determinants, unchanged over time. Study II examined the association of adult SRH with adverse material conditions (eco-nomic stress in the family) in childhood as well as adverse psychosocial conditions (condescending treatment) in childhood. Both economic stress and condescending treatment in childhood were strongly associated with poorer adult SRH. These associations were attenuated, but still statistically significant after adjustment for economic stress and condescending treatment in adulthood and other risk factors. Study III showed, after adjustment for age, economic difficulties, employment status and social support, a moderate association between educational level and psychological dis-tress, where low and medium educational levels were related to a lower risk of psychological distress. However, current economic difficulties showed a strong, and positive, association with psychological distress. Study IV showed that the shared pathways, including both material/structural fac-tors (e.g. financial buffer and unemployment) and psychosocial resources (e.g. optimism and social participation), explained about 40% of educational inequalities in SRH for both men and women aged 25–74 years. The pathways including only the independent effects of psychosocial resources (14% in men and 20% in women) or material/structural factors (9% and 18%, respectively) explained substantial but smaller proportions of the inequalities. 

In conclusion, in an adult population in the central part of Sweden, prevalence of poor SRH was, among men, twice as high in the low education group compared to the high education group during the first decade of the new millennium. Among women, educational inequalities were initially smaller, but increased over time to the same level as among men. However, when using self-reported psychological distress as health outcome, no corresponding educational inequalities were found. Instead, economic difficulties were an important determinant of psychological distress. SRH in adulthood was significantly associated with economic stress and condescending treatment during childhood, also when the same conditions in adulthood were taken into account. Material/structural factors and psychosocial resources explained more than half of the educational inequalities in SRH, and the majority of this contribution was in the form of a shared effect of material/structural factors and psychosocial resources. A shared effect means that a material/structural factor and a psychosocial resource are strongly associated, and that the combination of the two has an effect on the educational inequalities in SRH. Therefore, to reduce educational inequalities in SRH, interventions need to address both material/structural conditions and psychosocial resources. This needs to be done across educational groups, using a life course perspective, but with more intensive interventions in lower education groups. 

Abstract [sv]

Det är väl känt att hälsotillståndet skiljer sig mellan grupper med olika socioekonomisk situation, och detta är dokumenterat i de flesta länder. Dessa skillnader följer en gradient, så att hälsotillståndet är gradvis sämre för varje lägre nivå i den sociala hierarkin. Noterbart är att även välfärdslandet Sverige uppvisar påtagliga skillnader i hälsa mellan grupper med olika socioekonomisk situation, och att dessa skillnader har ökat under de senaste decennierna. 

Olika typer av bestämningsfaktorer, såsom materiella/strukturella faktorer, levnadsvanor och psykosociala faktorer, har visats förklara befolkningens hälsoutveckling. Ojämlikhet i hälsa uppkommer när fördelningen av bestämningsfaktorer skiljer sig mellan olika grupper, vilket ofta sker genom hela livet. Medan tidigare studier fokuserade på betydelsen av enskilda faktorer för ojämlikhet i hälsa, har forskningen på senare tid visat att flera av dessa ofta interagerar, och samverkar till att bidra till skillnader i hälsa mellan grupper. Det har dock hittills inte varit möjligt att kvantifiera hur stor del av ojämlikheten i hälsa som varje typ av bestämningsfaktor bidrar till på egen hand och hur stor del som uppstår genom samverkan mellan flera olika typer av bestämningsfaktorer. 

Det övergripande syftet med denna avhandling var att undersöka hur olika bestämningsfaktorer kan förklara ojämlikhet i självrapporterad hälsa mellan grupper med olika utbildningsnivå i en svensk population, särskilt hur materiella/strukturella faktorer och psykosociala resurser bidrar. 

Avhandlingen baseras på fyra delstudier. I studie I och IV användes data från studierna Liv & hälsa, tvärsnittsundersökningar som genomfördes i form av postenkäter 2000, 2004 och 2008 i fem län i mellersta Sverige. Det totala antalet svarande per år var ungefär 35,000, med en svarsfrekvens på mellan 60% och 67%. I studie II och III användes data från ett förstärkt urval i den nationella folkhälsoenkäten Hälsa på lika villkor från 2012, även den en tvärsnittsundersökning baserad på en enkät. Det förstärkta urvalet gjordes i fyra län i mellersta Sverige, och bestod av 26,706 svarande, motsvarande en svarsfrekvens på 53%. Som utfallsvariabel användes i studierna I, II och IV självskattad hälsa (SRH), och i studie III psykiskt välbefinnande. Storleken på ojämlikheten i SRH skattades med hjälp av ratkvoter och ratskillnader. Sambanden mellan bestämningsfaktorer och hälsoutfall skattades med hjälp av logistisk regression, och analysen av i vilken mån bestämningsfaktorernas bidrag till ojämlikhet i SRH bestod i oberoende bidrag eller i form av bidrag där flera typer av bestämningsfaktorer samverkade gjordes med hjälp av strukturella ekvationsmodeller (SEM). 

Resultaten från studie I visade att bland männen var förekomsten av dålig SRH dubbelt så stor i gruppen med låg utbildning, jämfört med i gruppen med hög utbildning, vilket var oförändrat mellan 2000 och 2008. Hos kvinnorna var skillnaderna i SRH mellan grupper med olika utbildningsnivå mindre 2000, men ökade till 2008 (från 1.7 till 2.1). Denna ökning berodde huvudsakligen på växande skillnader i den yngsta åldersgruppen (25–34 år). Fördelningen av bestämningsfaktor var genomgående till nackdel för gruppen med lägst utbildning, där de mest påtagliga skillnaderna gällde ekonomisk buffert, rökning och optimism. Dessa skillnader var huvudsakligen oförändrade över tid. I studie II undersöktes sambandet mellan materiella förhållanden (ekonomisk stress i familjen) respektive psykosociala förhållanden (utsatthet för nedlåtande behandling) under uppväxten och SRH som vuxen. Både ekonomisk stress och nedlåtande behandling under uppväxten hade starkt samband med SRH i vuxen ålder. Sambandet försvagades något, men var fortfarande statistiskt signifikant efter justering för motsvarande förhållanden som vuxen och för andra riskfaktorer. Resultaten från studie III visade på ett måttligt samband mellan utbildningsnivå och nedsatt psykiskt välbefinnande. Efter att ha tagit hänsyn till ålder, ekonomiska svårigheter, sysselsättning och socialt stöd, var förekomsten av nedsatt psykiskt välbefinnande något större bland dem med hög utbildning, jämfört med dem med låg eller medellång utbildning. Däremot fanns ett starkt positivt samband mellan ekonomiska svårigheter och nedsatt psykiskt välbefinnande. Resultaten från studie IV visade att de förklaringskedjor som inkluderade den gemensamma effekten av både materiella/ strukturella faktorer (t.ex. ekonomisk buffert och arbetslöshet) och psykosociala resurser (t.ex. optimism och socialt deltagande) förklarade ungefär 40% av skillnaderna i SRH mellan olika utbildningsnivåer, både bland kvinnor och män i åldern 25–75 år. De oberoende effekterna av psykosociala resurser (14% hos män and 20% hos kvinnor) eller materiella/ strukturella faktorer (9% respektive 18%) förklarade en mindre del av skillnaderna. 

Sammanfattningsvis visade resultaten från studierna att män med låg utbildning hade dubbelt så stor andel med mindre god SRH jämfört med högutbildade, och att detta var oförändrat under åren 2000 till 2008. Hos kvinorna var skillnadrna inledningsvis mindre men ökade över tid. När psykiskt välbefinnande användes som mått på hälsa fanns förhållandevis små skillnader mellan utbildningsgrupper, med ett omvänt samband där hög utbildning relaterade till något sämre psykiskt välbefinnande. Däremot fanns ett starkt samband mellan ekonomisk stress och nedsatt psykiskt välbefinnande. SRH i vuxen ålder påverkades av utsatta uppväxtvillkor i form av ekonomisk stress och nedlåtande behandling, också efter att hänsyn tagits till motsvarande förhållanden som vuxen. Slutligen framkom att materiella/ strukturella faktorer och psykosociala resurser förklarade mer än hälften av ojämlikheten i SRH mellan utbildningsnivåer, och att majoriteten av detta bidrag bestod av gemensamma effekter där dessa båda typer av bestämningsfaktorer samverkar. För att minska utbildningsrelaterad ojämlikhet i SRH krävs därför interventioner både avseende materiella/ strukturella förhållanden och psykosociala resurser. Eftersom ojämlikheten följer en social gradient behöver insatserna ske universellt, d.v.s. omfatta alla men i proportion till behoven. Resultatet illustrerar också betydelsen av ett livsloppsperspektiv i detta arbete.  

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2021. p. 111
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1786
National Category
Public Health, Global Health and Social Medicine
Identifiers
urn:nbn:se:liu:diva-178662 (URN)10.3384/diss.diva-178662 (DOI)9789179296339 (ISBN)
Public defence
2021-09-24, Berzeliussalen, Building 463 and online., Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Note

Funding agencies:

FoU-centrum, Landstinget Sörmland

Revisions:

2021-08-26 The thesis was first published online. The online published version reflects the printed version. 

2022-04-27 The thesis was updated with an errata list which is downloadable from this page. Before this date the PDF was downloaded 111 times.

Available from: 2021-08-26 Created: 2021-08-26 Last updated: 2025-02-20Bibliographically approved

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