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Social inequity in health: Explanation from a life course and gender perspective
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: A boy child born in a Gothenburg suburb has a life expectancy that is nine years shorter than that of another child just 23 km away, and among girls the difference is five years. There is no necessary biological reason to this observed difference. In fact, like life length, most diseases follow a social gradient, even in a country like Sweden where many believe there is no class inequity. This social inequity in health tells us that some of us are not achieving our potential in health or in life length compared to our more fortunate fellow citizens.

Aim: This thesis attempts to explore the patterns of health inequities and the pathways by which health inequities develop from a life course and gender perspective. In particular focuses on the importance of material, behavioural, health related and psychosocial circumstances from adolescence to adulthood in explaining social inequity in musculoskeletal disorders (MSDs), obesity, smoking, and social mobility.

Method: All four papers of this thesis were based on quantitative analyses of data from a 14-year follow-up study. The baseline survey was conducted in 1981 in Luleå, Sweden. The survey included all 16-year-old pupils born in 1965. A total of 1081 pupils (575 boys and 506 girls) were surveyed. They were followed up at ages 18, 21 and 30 years with comprehensive self-administered questionnaires. The response rate was 96.5% throughout the 14-year follow-up. In addition to the questionnaires data, school records, and interviews with nurse and teachers’ were used.

Results: There were no class or gender differences in MSDs and in obesity during adolescence, but significantly more girls than boys were smokers. Class and gender differences had emerged when they reached adulthood with more women reporting to have MSDs but more men being overweight and obese. Women continued to be smokers at a higher rate than men through to adulthood. When an intersection between class and gender was considered, a more complex picture emerged. For example, not all women had higher prevalence of MSDs or smoked more than men, rather men with high socioeconomic position (SEP) had lower prevalences of MSDs and smoking than women with high SEP; and these high SEP women had lower prevalences than men with low SEP. The worst-off group was women with low SEP. The obesity pattern was quite the contrary, where women with high SEP had a lower prevalence of obesity than women with low SEP; and these low SEP women had a lower prevalence than men with high SEP. The worst-off group was men with low SEP. Regarding social mobility, health status (other than height in women) and ethnic background were not associated with mobility either for men or women.

The results indicated that unequal distribution of material, psychosocial, health and health related behavioural factors during adolescence, young adulthood and adulthood accounted for the observed social gradients and social mobility. However, several factors from adolescence appeared to be more important for women while recent factors were more important for men. Important adolescent factors for social inequity and downward mobility were: unfavourable material circumstances defined as low SEP of parent, unemployed family member, and had no own room during upbringing; unfavourable psychosocial circumstances defined as parental divorce, poor contact with parents, being less liked in school, and low school control; and poor health related behaviour defined as smoking and physical inactivity. Among these factors, being less liked in school showed consistent association with all outcome measures of this thesis. Being less liked by the teachers and students was found to be more common among adolescents whose parents had low SEP. Men and women who were less liked in school during their adolescence were more likely as adults to be smokers, obese (only women), and downwardly mobile. The dominant adult life factor that contributed to class inequity in MSDs for men and women was physical heavy working conditions, which attributed to an estimated 46.9% (women) and 49.5% (men) of the increased risk in MSDs of the lower SEP group. High alcohol consumption among men with low SEP was an additional factor that contributed to class inequities in health and social mobility.

Conclusion: Social patterning of health in this cohort was gendered and age specific depending on the outcome measures. Unfavourable school environment in early years had long lasting negative influence on later health, health behavior and SEP. The thesis supports the notion of accumulation of risk that social inequities in health occurs due to accumulation of multiple adverse circumstances among the lower SEP group throughout their life course. Schools should be used as a setting for interventions aimed at reducing socioeconomic inequities in health. The detailed policy implications for reduction of social inequities in health among men and women are discussed.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, Institutionen för Folkhälsa och klinisk medicin , 2010. , 83 p.
Series
Umeå University medical dissertations, ISSN 0346-6612
Keyword [en]
social inequity, pathways, social causation, life course, gender, intersectionality, smoking, musculoskeletal disorders, obesity, social mobility, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology Public Health, Global Health, Social Medicine and Epidemiology Public Health, Global Health, Social Medicine and Epidemiology Gender Studies
Research subject
Epidemiology; hälso- och sjukvårdsforskning; Nutrition; Occupational and Environmental Medicine
Identifiers
URN: urn:nbn:se:umu:diva-31849ISBN: 978-91-7264-950-7 (print)OAI: oai:DiVA.org:umu-31849DiVA: diva2:297883
Public defence
2010-03-12, Tandläkarehögskolan, vån. 9, Sal D, Norrlands universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2010-02-19 Created: 2010-02-18 Last updated: 2010-02-19Bibliographically approved
List of papers
1. The influence of factors identified in adolescence and early adulthood on social class inequities of musculoskeletal disorders at age 30: A prospective population-based cohort study
Open this publication in new window or tab >>The influence of factors identified in adolescence and early adulthood on social class inequities of musculoskeletal disorders at age 30: A prospective population-based cohort study
2004 (English)In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 33, no 6, 1353-1360 p.Article in journal (Refereed) Published
Abstract [en]

Background Social class inequities have been observed for most measures of health. A greater understanding of the relative importance of different explanations is required. In this prospective population-based cohort study we explored the contribution of factors, ascertained at different stages between adolescence and early adulthood, to social class inequities in musculoskeletal disorders (MSD) at age 30.

Methods We used data from 547 men and 497 women from a town in north Sweden who were baseline examined at age 16 and followed up to age 30. Using logistic regression models, we estimated the unadjusted odds ratios (OR) for MSD for blue-collar versus white-collar workers in men and women separately. We assessed the contribution of different factors identified between adolescence and early adulthood by comparing the unadjusted OR for social class differences with OR adjusted for these explanatory factors.

Results We found significant class differences at age 30 with higher MSD among blue-collar workers (OR = 2.03 in men [95% CI: 1.42, 2.90] and 1.98 in women [95% CI: 1.29, 3.02]). After adjustment for explanatory factors, class differences decreased and were no longer significant, with OR of 1.20 in men (95% CI: 0.76, 1.95) and 1.18 in women (95% CI: 0.69, 2.03). School grades at age 16; being single and alcohol consumption at age 21; having children, restricted financial resources, physical activity, alcohol consumption, smoking, and working conditions at age 30 were important for men; parents' social class, school grade, smoking and physical activity at age 16; being single at age 21; and working conditions at age 30 were important for women.

Conclusion The accumulation of adverse behavioural and social circumstances from adolescence to early adulthood may be an explanation for the class differences in MSD at age 30. Interventions aimed at reducing health inequities need to consider exploratory factors identified at early and later stages in life, also including structural determinants of health.

Place, publisher, year, edition, pages
International Epidemiological Association, 2004
Keyword
Social class, inequity, neck pain, low back pain, adolescence, adulthood, longitudinal, prospective study
Identifiers
urn:nbn:se:umu:diva-6087 (URN)10.1093/ije/dyh237 (DOI)
Note
Författaren har senare bytt efternamn till Novak. Available from: 2008-01-09 Created: 2008-01-09 Last updated: 2010-11-23Bibliographically approved
2. A life-course approach in explaining social inequity in obesity among young adult men and women.
Open this publication in new window or tab >>A life-course approach in explaining social inequity in obesity among young adult men and women.
2006 (English)In: International Journal of Obesity, ISSN 0307-0565, Vol. 30, no 1, 191-200 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To examine the cumulative influence of adverse behavioural, social, and psychosocial circumstances from adolescence to young adulthood in explaining social differences in overweight and obesity at age 30 years and if explanations differ by gender.

Design: A 14-year longitudinal study with 96.4% response rate.

Subject: Data from 547 men and 497 women from a town in north Sweden who were baseline examined at age 16 years and prospectively followed up to age 30 years.

Measurements: Overweight and obesity were ascertained at ages 16 and 30 years. Occupation and education were used to measure socioeconomic status. The explanatory measurements were: age at menarche, smoking, physical activity, alcohol consumption, TV viewing, home and school environment, social support, social network, and work environment.

Results: No gender or social difference in overweight was observed at age 16 years. At age 30 years, significantly more men than women (odds ratio (OR)¼2.81, 95% confidence interval (CI) 2.14–3.68) were overweight or obese. Educational level was associated with overweight at age 30 years, but not occupational class. Both men (OR¼1.55, 95% CI 1.10–2.19) and women (OR¼1.78, 95% CI 1.16–2.73) with low education (p11 years) were at risk of overweight. The factors that explained the educational gradient in overweight among men were low parental support in education during adolescence, and physical inactivity, alcohol consumption, and nonparticipation in any association during young adulthood. The educational gradient in overweight in women was explained mostly by adolescence factors, which include early age at menarche, physical inactivity, parental divorce, not being popular in school, and low school control. Restricted financial resource during young adulthood was an additional explanatory factor for women. All these factors were significantly more common among men and women with low education than with high education.

Conclusion: Social inequities in overweight reflect the cumulative influence of multiple adverse circumstances experienced from adolescence to young adulthood. Underlying pathways to social inequity in overweight differ between men and women. Policy implications to reduce social inequity in overweight include reduction of social differences in health behaviours and social circumstances that take place at different life stages, particularly psychosocial circumstances during adolescence.

Place, publisher, year, edition, pages
Nature Publishing Group, 2006
Keyword
gender, inequity, behavior factors, social factors, psychosocial factors, longitudinal study
Identifiers
urn:nbn:se:umu:diva-6307 (URN)10.1038/sj.ijo.0803104 (DOI)16172616 (PubMedID)
Available from: 2008-01-03 Created: 2008-01-03 Last updated: 2010-02-19Bibliographically approved
3. Inequalities in smoking: influence of social chain of risks from adolescence to young adulthood: a prospective population-based cohort study.
Open this publication in new window or tab >>Inequalities in smoking: influence of social chain of risks from adolescence to young adulthood: a prospective population-based cohort study.
2007 (English)In: International Journal of Behavioral Medicine, ISSN 1070-5503, E-ISSN 1532-7558, Vol. 14, no 3, 181-7 p.Article in journal (Refereed) Published
Place, publisher, year, edition, pages
Springer Science & Business Media B.V., 2007
Keyword
smoking, inequality, social risk factors, cohort study, adolescent, adult
Identifiers
urn:nbn:se:umu:diva-6942 (URN)18062061 (PubMedID)
Available from: 2007-12-28 Created: 2007-12-28 Last updated: 2010-11-23Bibliographically approved
4. Social and health-related correlates of intergenerational and intragenerational social mobility among Swedish men and women
Open this publication in new window or tab >>Social and health-related correlates of intergenerational and intragenerational social mobility among Swedish men and women
2012 (English)In: Public Health, ISSN 0033-3506, E-ISSN 1476-5616, Vol. 126, no 4, 349-357 p.Article in journal (Refereed) Published
Abstract [en]

Background: The present study explored the pattern and the determinants of social mobility among men and women both at inter and intragenerational transitional periods. Specifically the study addressed what impact do the various health related measures, health-behaviours, psychosocial environments at home and school, material resources, and ethnicity have on the chances and the direction of social mobility.

Methods: A Swedish 14-year prospective longitudinal study with 96.5% response rate. Detail information on 546 men and 495 women regarding their occupation, health status, health-related behaviour, psychosocial environment at home and school, material recourses and ethnicity prior to mobility were available from ages 16, 21 and 30. Odds Ratios and 99% confidence interval were calculated using logistic regression to determine social mobility.

Results: At the inter-generational analyses, being liked in school (liked by the teachers and students) predicted upward mobility in men and women. Additionally, being taller predicted upward mobility in women. Downward mobility was predicted by being less liked in school and smoking for both men and women. Additionally, having an unemployed family member for men and not having an own room for women predicted downward mobility. At the intra-generational analyses, less alcohol consumption for men and better financial resources for women predicted upward mobility. Downward mobility among men was predicted by smoking and having restricted financial resources. The chances and the directions of mobility were not influenced by ethnic background.

Conclusions: Except height among women, health status was not associated with mobility in this cohort for men or for women neither internor intra-generationally, however material deprivation, economical deprivation, poor health behaviours, and unfavourable school environment were.

Keyword
Inter-generational mobility, intra-generational mobility, determinants, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-31874 (URN)10.1016/j.puhe.2012.01.012 (DOI)000302121100015 ()22444320 (PubMedID)
Available from: 2010-02-19 Created: 2010-02-19 Last updated: 2012-05-29Bibliographically approved

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