Implications of socio-economic differentials in mortality for the health system

The premise of this discussion is that a systematic and continuous monitoring system is required to assemble data on the social indicator "socio-economic differences in mortality." Attention is directed to 5 particular types of data: secular trends; class differentials and age; linearity versus dichotomy; cross-cutting variables; and downward mobility and biological selection. The following 2 basic questions are examined and answered with a qualified "yes:" 1) does the health care system have any relevance to mortality differentials; and 2) can a health care system have any degree of meaninful autonomy from the overall social system. The policy implications of this analysis are reviewed in terms of the value content of medical education, the organization of the health care system, the emphasis on health, and the focus on the community. The concepts of control and power are analyzed as the key to socioeconomic differentials. Emphasis on differential exposures to "stressors" is rejected for what is termed "a sense of coherence" -- a global orientation which emerges, or fails to emerge among the lower classes, against the background of a high level of generalized resistance resources. Essentially the problem is that the constricted, emergency, powerless, and unpredictable character of lower social class existence prevents individuals of lower class and groups from being able to cope with stressors. Ways that the health care system can strengthen the sense of coherence of the lower classes include the following: a formal monitoring system in each society; caution in assuming that technological advances, environmental control, and health education are egalitarian in their consequences; and the need to identify high-risk groups within the lower classes.     

Urban determinants of racial differentiation in infant mortality

This study relates differential socioeconomic status between blacks and whites to racial differentiation in infant mortality rates. The basic assumption is that decreases in socioeconomic differentiation and related variables lead to decreases in the black—white infant mortality differential. A comparative approach based on aggregate measures of socioeconomic differentiation is utilized to compare sixty-one United States urban places. Path analysis shows that neonatal mortality differentiation is virtually unaffected by socioeconomic differentials while decreased racial differences in hospital births tend to increase neonatal mortality differentiation. In contrast, postneonatal differentiation is affected by socioeconomic differentiation, especially along the dimensions of income, education, and regional location. It is concluded that despite some suggestions that infant mortality is no longer responsive to socioeconomic factors, postneonatal differentation is affected by socioeconomic differentials when comparison is based on city units.     

The future of sex mortality differentials in industrialized countries: A structural hypothesis

This paper advances the hypothesis that the future of sex mortality differentials in industrialized countries may depend on the future mortality rates of blue collar men. Data are presented to support the argument that mortality rates from ischemic heart disease for this population subgroup play a significant role in current differentials and, furthermore, that sexsocial class-mortality differentials correspond to social structural differences in protection against and/or exposure to health risks. Research and policy implications of this argument are addressed briefly.The views expressed in this paper are those of the authors and do not necessarily reflect the policy or views of the World Health Organization.     

Environmental Hazards,Migration, and Race

This study contributes to our understanding of the association between internal migration patterns and environmentally hazardous facilities, with a focus upon race-specific outmigration at the county-level, nationwide. Among research suggesting inequalities with regard to the social distribution of environmental risk, selective migration is often implied to be a key dynamic leading to differential exposure to proximate environmental hazards. Nonetheless, the models presented here provide no evidence of differential migratory response by race to environmentally hazardous facilities, net of a wide array of socioeconomic controls for labor force opportunity, climate, and demographic structure. Future research should consider these associations at more precise geographies and/or at the individual level.     

The Life Course,Cohort Dynamics,and International Differences in Aging Trajectories

In recent years, population health research has focused on understanding the determinants of later-life health. Two strands of that work have focused on (1) international comparisons of later-life health and (2) assessing the early-life origins of disease and disability and the importance of life course processes. However, the less frequently examined intersection of these approaches remains an important frontier. The present study contributes to the integration of these approaches. We use the Health and Retirement Study family of data sets and a cohort dynamic approach to compare functional health trajectories across 12 high-income countries and to examine the role of life course processes and cohort dynamics in contributing to variation in those trajectories. We find substantial international variation in functional health trajectories and an important role of cohort dynamics in generating that variation, with younger cohorts often less healthy at comparable ages than the older cohorts they are replacing. We further find evidence of heterogeneous effects of life course processes on health trajectories. The results have important implications for future trends in morbidity and mortality as well as public policy.     

Occupational careers and mortality of elderly men

This article presents findings from an analysis of occupational differentials in mortality among a cohort of males aged 55 years and older in the United States for the period 1966-1983. Using the National Longitudinal Survey of Mature Men, we construct event histories for 3,080 respondents who reach the exact age of 55. The dynamics that characterize socioeconomic differentials in mortality are analyzed by evaluating the differential effects of occupation over the career cycle. Maximum likelihood estimates of hazard-model parameters show that the mortality of current or last occupation differs substantially from that of longest occupation, controlling for education, income, health status, and other sociodemographic factors. In particular, the rate of mortality is reduced by the substantive complexity of the longest occupation while social skills and physical and environmental demands of the latest occupation lower mortality.     

Political demography: Powerful trends under-attended by demographic science

The interconnections between politics and the dramatic demographic changes under way around the world have been neglected by the two research disciplines that could contribute most to their understanding: demography and political science. Instead, this area of ‘political demography’ has largely been ceded to political activists, pundits, and journalists, leading often to exaggerated or garbled interpretation. The terrain includes some of the most politically sensitive and contested issues: alleged demographically determined shifts in the international balance of power; low fertility, population decline, and demographic ageing; international migration; change in national identity; and compositional shifts in politically sensitive social categories and human rights. Meanwhile many governments and non-governmental actors have actively pursued varieties of ‘strategic demography’, deploying fertility, mortality, or migration as instruments of domestic or international policy. Political scientists and demographers could and should use their knowledge and analytic techniques to improve understanding and to moderate excessive claims and fears on these topics.     

Socioeconomic Determinants of White and Black Males’ Life Expectancy Differentials, 1980

Epidemiological transition theory suggests that two population existing under disparate socioeconomic conditions would have different life expectancies as the result of cause-of-death differences. The effect of racial socioeconomic differentials on the total racial life expectancy differential are examined as they act through specific cause-of-death differentials. Results suggest that residential isolation of blacks has a strong effect on the total life expectancy differential as it acts through the racial homicide differential. The racial unemployment difference also has a strong effect on the total differential as it acts through the racial heart disease differential. Implications of the findings for reducing life expectancy differentials are discussed.     

Measuring socioeconomic status in health research in developing countries: Should we be focusing on households,communities or both?

Research on the effects of socioeconomic well-being on health is important for policy makers in developing countries, where limited resources make it crucial to use existing health care resources to the best advantage. This paper develops and tests a set of measures of socioeconomic status indicators for predicting health status in developing countries. We construct socioeconomic indexes that capture both household and community attributes so as to allow us to separate the social from the purely economic dimensions of the socioeconomic status within a cross-national perspective, with applications to data from Demographic and Health Surveys (DHS) fielded in five African countries in the 1990s. This study demonstrates the distinctive contributions of socioeconomic indexes measured at the household vs. community level in understanding inequalities in health and survival and underlines the importance of going beyond the purely economic view of socioeconomic status to cover the multidimensional as well as multilevel concept of economic and social inequality.     

A summary analysis of the 3rd inquiry

20 ESCAP member countries responded to the "Third Population Inquiry among Governments: Population policies in the context of development in 1976." The questionnaire sent to the member countries covered economic and social development and population growth, mortality, fertility and family formation, population distribution and internal migration, international migration, population data collection and research, training, and institutional arrangements for the formulation of population policies within development. Most of the governments in the ESCAP region that responded indicate that the present rate of population growth constrains their social and economic development. Among the governments that consider the present rate of population growth to constrain economic and social development, 13 countries regarded the most appropriate response to the constraint would include an adjustment of both socioeconomic and demographic factors. 11 of the governments regarded their present levels of average life expectancy at birth "acceptable" and 7 identified their levels as "unacceptable." Most of the governments who responded consider that, in general, their present level of fertility is too high and constrains family well-being. Internal migration and population distribution are coming to be seen as concerns for government population policy. The most popular approaches to distributing economic and social activities are rural development, urban and regional development and industrial dispersion. There was much less concern among the governments returning the questionnaire about the effect of international migration than internal migration on social and economic development.     

Public policy and the socioeconomic mortality differential in infancy

This paper discusses some of the findings and policy implications of a recently completed study of socioeconomic differences in infant mortality in eight metropolitan areas of Ohio at three points in time. The study revealed that, in spite of a considerable decline in the overall rate of infant mortality since 1960, the inverse socioeconomic differential remains as wide as ever. This clearly suggests that, although maternal and child health has improved overall, the lower economic groups in our society still do not have equal access either to health care or to other amenities essential to the maintenance of good health. Moreover, consideration of recent and current policy proposals with respect to welfare programs in general, and maternal and child health care programs in particular, leads to the conclusion that this situation is not likely to change in the near future. Finally, some policy recommendations for enhancing the health status of low-income families are offered.The research on which this paper is based has been supported by the Maternal and Child Health and Crippled Children's Services Research Grants Program (Grant MCJ-390520-01); Bureau of Community Health Services, HSA, PHS, DHHS.     

Racial differences in occupational status and income in South Africa, 1880 and 1881

Using data on employed men from the 1980 and 1991 South African Censuses, we analyze the determinants of occupational status and income. Whites are found to have much higher occupational status, and especially income, than members of other racial groups. Most of the racial differentials in occupational status can be explained by racial differences in the personal assets that determine occupational attainment (especially education), but only a much smaller fraction of the White/non-White income differential can be so explained. Despite a modest reduction between 1980 and 1991 in the role of race in socioeconomic attainment, the overall picture shows more stability than change.     

Residence background,socioeconomic status,and fertility

Previous research has demonstrated that socioeconomic differentials in fertility are heavily influenced by couples with rural background. These studies show an inverse relationship between fertility and socioeconomic status for couples of rural background, but no relationship for urbanorigin couples. The effect of urban background on rural fertility differentials has not been examined. This study investigates the potential effect of urban-origin couples on socioeconomic differences in fertility in rural areas. Data from the 1967 Survey of Economic Opportunity are analyzed to show that rural socioeconomic fertility differences are not influenced by the presence of persons of urban background.     

Neighborhood Concentrated Disadvantage and Adult Mortality: Insights for Racial and Ethnic Differences

While racial and ethnic differences in mortality are pervasive and well documented, less is known about how mortality risk varies by neighborhood socioeconomic status across racial and ethnic identity. We conducted a prospective analysis on a sample of adults living at or below 300% poverty with 8 years of the National Health Interview Survey (N = 159,400) linked to 11,600 deaths to examine the association between neighborhood disadvantage and mortality for non-Hispanic whites, non-Hispanic blacks, and U.S.- and foreign-born Hispanics. Using multilevel logistic regression, we find that the probability of death from any cause for lower-income adults is higher in more-disadvantaged neighborhoods, compared to less-disadvantaged neighborhoods, but only for whites. The adjusted likelihood of death for blacks and foreign-born Hispanics is not associated with neighborhood disadvantage, and the likelihood of death for U.S.-born Hispanics is lower in more-disadvantaged neighborhoods. While future research and policy should focus on improving health-promoting resources in all communities, care should be given to better understanding why race/ethnic groups have differential mortality returns with respect to area-specific socioeconomic conditions.     

Reproducing inequalities: Luck, wallets, and the enduring effects of childhood health

In this article, I argue that research on social stratification, on intergenerational transmission of inequalities, and on the theory of factor payments and wage determination will be strengthened by studying the role played by early childhood health. I show that the inclusion of such a factor requires researchers to integrate theories in each of these fields with new theories linking early childhood health conditions and events that occur at later stages in the life course of individuals, particularly physical and mental health as well as disability and mortality. The empirical evidence I gather shows that early childhood health matters for the achievement of or social accession to, adult social class positions. Even if the magnitude of associations is not overwhelming, it is not weaker than that found between adult social accession and other, more conventional and better-studied individual characteristics, such as educational attainment. It is very likely that the evidence presented in this article grossly underplays the importance of early childhood health for adult socioeconomic achievement.     

Measuring socioeconomic mortality differentials over time

Using 1973 Current Population Survey data matched to 1973-1978 Social Security mortality records, this study measures the relationship between the income and education of men and their subsequent mortality. The estimated relationships are compared with socioeconomic mortality differentials found by Kitagawa and Hauser in their study of 1960 census-death certificate matched data. The comparison suggests that there has been no improvement in the relative mortality experience of low socioeconomic status men. More generally, the article discusses how Social Security data could be used to monitor, on a continual basis, our progress toward eradicating significant mortality differentials in the United States.     

Explaining son preference in rural India: the independent role of structural versus individual factors

Much research has been done on demographic manifestations of son preference, particularly girls’ excess mortality; however, there is less research that focuses on son preference itself. This paper analyzes the determinants of son preference in rural India. We separate the independent, relative effects of characteristics of individual women and their households, village opportunities for women and village development, and social norms. We look at both socioeconomic and sociocultural variables. Finally, we examine whether predictors of son preference differ by desired family size. Our data come from the National Family Health Survey (NFHS) India, 1992–1993. We use an ordered logit model, with dummy variables for state of residence. Our analysis shows that women’s education, particularly at secondary and higher levels, is consistently and significantly associated with weaker son preference, regardless of desired family size. Once factors measuring social norms, such as marriage customs, caste and religion, are included, economic wealth and women’s employment at household or village levels are not significant. Media access remains significant, suggesting an influence of “modernizing” ideas. Among social factors, caste and religion are associated with son preference but, once state of residence is controlled for, marriage patterns and cultivation patterns are insignificant. The strength and significance for son preference of many determinants differs by desired family size. Our results suggest that policy makers seeking to influence son preference need to identify and target different policy levers to women in different fertility and social contexts, rather than try an approach of one size that fits all.     

India's population: second and growing

Attention in this discussion of the population of India is directed to the following: international comparisons, population pressures, trends in population growth (interstate variations), sex ratio and literacy, urban-rural distribution, migration (interstate migration, international migration), fertility and mortality levels, fertility trends (birth rate decline, interstate fertility differentials, rural-urban fertility decline, fertility differentials by education and religion, marriage and fertility), mortality trends (mortality differentials, health care services), population pressures on socioeconomic development (per capita income and poverty, unemployment and employment, increasing foodgrain production, school enrollment shortfalls), the family planning program, implementing population policy statements, what actions would be effective, and goals and prospects for the future. India's population, a total of 684 million persons as of March 1, 1981, is 2nd only to the population of China. The 1981 population was up by 136 million persons, or 24.75%, over the 548 million enumerated in the 1971 census. For 1978, India's birth and death rates were estimated at 33.3 and 14.2/1000 population, down from about 41.1 and 18.9 during the mid-1960s. India's current 5-year plan has set a goal of a birth rate of 30/1000 population by 1985 and "replacement-level" fertility--about 2.3 births per woman--by 1996. The acceleration in India's population growth has come mainly in the past 3 decades and is due primarily to a decline in mortality that has markedly outstripped the fertility decline. The Janata Party which assumed government leadership in March 1977 did not dismantle the family planning program, but emphasis was shifted to promote family planning "without any compulsion, coercion or pressures of any sort." The policy statement stressed that efforts were to be directed towards those currently underserved, mainly in rural areas. Hard targets were rejected. Over the 1978-1981 period the family planning program slowly recovered. By March 1981, 33.4 million sterilizations had been performed since 1956 when statistics were 1st compiled. Another 3 million couples were estimated to be using IUDs and conventional contraceptives.     

The effects of status on women’s autonomy in Bolivia,Peru,and Nicaragua

A recent ideological revolution promoting women’s status has raised questions concerning determinants of autonomy and their implications for policy formation. This study seeks to identify objective indicators determinant of autonomy, and then examine their relationship in light of women’s subjective experiences of autonomy. Potential determinants include education, literacy, household size, age at marriage, employment, and socioeconomic status. Analyses are based on these data sets: the 2000 Bolivia Family Interaction and Children’s Well-Being (FICW) Survey, the 2000 Peru Demographic Health Survey and the 1997/1998 Nicaraguan Demographic and Health Survey. Our findings indicate that autonomy is multidimensional. Utilizing Structural equation modeling, we identify two major domains autonomy: decision-making autonomy and personal autonomy in Bolivia, and family autonomy and public autonomy in Nicaragua and Peru. This study shows that each of our specified determinants has some influence on autonomy, with education and socioeconomic status being the most important. We conclude that policies designed to change educational, economic, and familial characteristics of women will only have a modest impact on women’s overall sense of autonomy.     

Some aspects of socio-economic determinants of mortality in tropical Africa

Measurements of mortality levels and trends continue to be inadequate in Africa, largely because of the lack of reliable and adequate information on deaths. A series of estimates depicting mortality levels and trends has been prepared by demographers, different kinds of data and employing different estimation procedures, but knowledge of the "true" structure of mortality in tropical Africa is virtually nonexistent. Because of these problems only a "bird's eye view" of the prevailing situation in tropical Africa is presented. The discussion -- directed to mortality by sex and age, by residence, and by cause -- is based on secondary and fragmentary data. Socioeconomic and cultural determinants of mortality are also examined. Available information on male and female mortality indicates that the death rates for males are higher than they are for females. Early childhood mortality (1-4 years) in tropical Africa is relatively high compared with the other age groups, including infants. Mortality differentials have been noted among geographical and administrative units and subdivisions of populations within the various countries of tropical Africa. Also, urban dwellers enjoy a higher expectation of life at birth than do rural dwellers. Communicable diseases are the main killers in tropical Africa. Persistent poverty and malnutrition, poor housing, unhealthy conditions in the growing cities, nonexistence of health facilities in the rural areas, rapid population expansion, and low levels of education are among the factors impeding progress in reducing mortality in tropical Africa. The need exists to express development goals in terms of the progressive reduction and eventual elimination of malnutrition, disease, illiteracy, squalor, and inequalities. Future trends in mortality in tropical Africa may depend more than they have in the recent past on economic and social development.