Explaining the US Health Disadvantage: The role of social inequalities

The aim of this thesis is to gain insight into the role of social inequalities in explaining the differences in health between the United States and Western Europe. The first part of this thesis assesses the contribution of educational inequalities in health to the explanation of the US health disadvantage. The second part of this thesis assesses the contribut

Work-family typologies and mental health among women in early working ages

Better mental health is observed among women with a partner, children, or employment as compared with women without a partner, children, or employment, respectively. Moreover, women who fulfill all three roles are generally healthier than those with fewer roles. Because of significant changes in work-family life constellations over age, understanding these health differentials requires a life course approach. We linked work-family trajectories to mental health in mid-life for Finnish women using longitudinal registry data. Panel data from an 11% random sample of the population residing in Finland in any year between 1987 and 2007 and followed up until 2013 were used. Work-family combinations were based on partnership status, motherhood status, and employment status. Purchases of prescribed psychotropic medication were used as a measure of mental health. We used sequence analysis to identify 7 distinct groups of women based on their work-family trajectories between ages 20 to 42 years. The associations of typologies of trajectories with mental health at age 43 years were estimated with logistic regression models. Compared to employed mothers with a partner, all other women were more likely to have purchased any psychotropic medication at age 43; especially women without a partner, children or employment and lone mothers had worse mental health. These disadvantages remained after controlling for psychotropic medication purchases earlier in life (to account for potential health selection). Adjusting for age at motherhood did not contribute to the better mental health of employed mothers with a partner. Women combining partnership, motherhood, and employment during early working ages had better mental health later in life than women with other work-family trajectories even after adjusting for mental health earlier in life. Interventions to improve the mental health of women living alone in mid-life, including lone mothers, and individuals without employment, may be needed

Cohabitation and mental health : Is psychotropic medication use more common in cohabitation than marriage?

Marriage is associated with better mental health. While research on the mental health of cohabiting individuals has increased in recent years, it has yielded mixed results thus far. We assessed whether the mental health of cohabiters is comparable to that of married individuals or those living alone using longitudinal data on psychotropic medication purchases. Panel data from an 11% random sample of the population residing in Finland for the years 1995 to 2007, with annual measurements of all covariates, were used. Ordinary least squares (OLS) models were applied to disentangle the relation between cohabitation and psychotropic medication purchases while controlling for relevant time-varying factors (age, education, economic activity, and number of children), and individual fixed effects (FE) models to further account for unobserved time-invariant individual factors. Our sample consisted of 63,077 men and 61,101 women aged 25 to 39 years in 1995. Descriptive results and the OLS model indicated that the likelihood of purchasing psychotropic medication was lowest for married individuals, higher for cohabiters, and highest for individuals living alone. This difference between cohabiting and married individuals disappeared after controlling for time-varying covariates (percent difference [% diff] for men: 0.3, 95% confidence interval [CI]: -0.0, 0.6; % diff for women: -0.2, 95% CI: -0.6, 0.2). Further controlling for unobserved confounders in the FE models did not change this non-significant difference between cohabiting and married individuals. The excess purchases of psychotropic medication among individuals living alone compared to those cohabiting decreased to 1.2 (95% CI: 1.0, 1.4) and 1.4 (95% CI: 1.1, 1.6) percentage-points in the fully-adjusted FE model for men and women, respectively. Similar results were found for all subcategories of psychotropic medication. In summary, these findings suggested that the mental health difference between cohabiting and married individuals, but not the difference between cohabiting individuals and those living alone, was largely due to selection.Peer reviewe

Assessing the impact of natural policy experiments on socioeconomic inequalities in health

Background: The scientific evidence-base for policies to tackle health inequalities is limited. Natural policy experiments (NPE) have drawn increasing attention as a means to evaluating the effects of policies on health. Several analytical methods can be used to evaluate the outcomes of NPEs in terms of average population health, but it is unclear whether they can also be used to assess the outcomes of NPEs in terms of health inequalities. The aim of this study therefore was to assess whether, and to demonstrate how, a number of commonly used analytical methods for the evaluation of NPEs can be applied to quantify the effect of policies on health inequalities. Methods: We identified seven quantitative analytical methods for the evaluation of NPEs: regression adjustment, propensity score matching, difference-in-differences analysis, fixed effects analysis, instrumental variable analysis, regression discontinuity and interrupted time-series. We assessed whether these methods can be used to quantify the effect of policies on the magnitude of health inequalities either by conducting a stratified analysis or by including an interaction term, and illustrated both approaches in a fictitious numerical example. Results: All seven methods can be used to quantify the equity impact of policies on absolute and relative inequalities in health by conducting an analysis stratified by socioeconomic position, and all but one (propensity score matching) can be used to quantify equity impacts by inclusion of an interaction term between socioeconomic position and policy exposure. Conclusion: Methods commonly used in economics and econometrics for the evaluation of NPEs can also be applied to assess the equity impact of policies, and our illustrations provide guidance on how to do this appropriately. The low external validity of results from instrumental variable analysis and regression discontinuity makes these methods less desirable for assessing policy effects on population-level health inequalities. Increased use of the methods in social epidemiology will help to build an evidence base to support policy making in the area of health inequalities

The relationship between living arrangements and higher use of hospital care at middle and older ages : to what extent do observed and unobserved individual characteristics explain this association?

Abstract Background Previous research has shown that certain living arrangements, such as living alone, are associated with worse health at older ages. We assessed the association between living arrangements and hospital care use among middle-aged and older adults, and investigated to what extent observed and unobserved individual characteristics explain this association. Methods Longitudinal Finnish registry data for men and women aged 50–89 years were used for the period 1987–2007. The relationship between living arrangements (based on whether an individual lived with a partner, other adults or alone, and whether they lived with minor/adult children) and heavy hospital care use (i.e., having been in hospital for 8 or more days in a year) was studied. First, we applied logistic regression models and linear probability models controlling for observed time-invariant factors (socioeconomic status measured by education, labour force status, and household income; and marital status), and then individual linear probability models with fixed-effects to further account for unobserved time-invariant individual characteristics in the measurement period. Analyses were done separately for 10 year age-groups. Results In the logistic regression models, men and women who lived alone had higher crude odds of heavy hospital care use than those living only with their partner. These odds ratios were highest for men and women in the youngest age category (50–59 years, 1.72 and 1.36 respectively) and decreased with age. Adjusting for observed time-invariant socioeconomic status attenuated these odds by 14–40%, but adjusting for marital status did not affect the results. Lower odds were observed among adults aged 50–59 years who lived with their partner and (minor or adult) children. But odds were higher for individuals aged 60–79 years who co-resided with their adult children, regardless of whether they lived with a partner. Adjusting for observed time-invariant factors generally did not change these results. After further adjusting for unobserved time-invariant individual characteristics in the individual fixed-effects models, most of these associations largely attenuated or disappeared, particularly for ages 80–89 years. Conclusions The association between living arrangements and higher use of hospital care at middle and older ages is largely explained by socioeconomic disadvantage and unobserved time-invariant individual characteristics

What's the difference? A gender perspective on understanding educational inequalities in all-cause and cause-specific mortality

BACKGROUND: Material and behavioural factors play an important role in explaining educational inequalities in mortality, but gender differences in these contributions have received little attention thus far. We examined the contribution of a range of possible mediators to relative educational inequalities in mortality for men and women separately.METHODS: Baseline data (1991) of men and women aged 25 to 74 years participating in the prospective Dutch GLOBE study were linked to almost 23 years of mortality follow-up from Dutch registry data (6099 men and 6935 women). Cox proportional hazard models were used to calculate hazard ratios with 95% confidence intervals, and to investigate the contribution of material (financial difficulties, housing tenure, health insurance), employment-related (type of employment, occupational class of the breadwinner), behavioural (alcohol consumption, smoking, leisure and sports physical activity, body mass index) and family-related factors (marital status, living arrangement, number of children) to educational inequalities in all-cause and cause-specific mortality, i.e. mortality from cancer, cardiovascular disease, other diseases and external causes.RE

Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies

Background: The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies. Methods: ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected. Results: At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals. Conclusions: The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®

Selection into maternity leave length and long-run maternal health in Germany

Existing literature shows the importance of maternity leave as a strategy for women to balance work and family responsibilities. However, only a few studies focused on the long-run impact of maternity leave length on maternal health. Therefore, how exactly they are related remains unclear. We examine women’s selection into different lengths of maternity leave as a potential explanation for the inconclusive findings in the literature on the association between maternity leave and maternal health. This study aims to unravel the association between maternity leave length and mothers’ long-term health in Germany. Drawing on detailed data from the German Statutory Pension Fund (DRV), we estimated the association between maternity leave length and sick leave from 3 years following their child’s birth for 4,243 women living in Germany in 2015 by applying discrete-time logistic regression. Our results show a negative relationship between maternity-leave length and long-term maternal health, likely driven by negative health selection. Long maternity leaves of more than 24 months were associated with worse maternal health in the long run, while a positive association emerged for vulnerable women with pre-existing health problems

Verbesserung der Sprechstunde mit chronisch kranken Kindern: Gesundheits-, Funktions- und Wohlergehensampel

Improving Communication Quality Caring for Children with Chronic Conditions: Health, Functioning and Wellbeing Traffic-Light Tool Abstract. Effective patient-doctor communication is a crucial aspect while caring for children with chronic conditions or disabilities. The Health, Functioning and Wellbeing Summary Traffic Light has been developed as a communication tool especially for these patients. In a two-month pilot phase the German version was evaluated by parents and physicians in a rehabilitation out-patient clinic setting. 71 % (n = 35/49) returned the evaluation form. The traffic-light tool was rated positive by 80 % of participants and physicians. It can be recommended as a useful tool for improved communication. The simple language version as well as translations into other languages and the use of a mobile App will facilitate its use. Its use is not limited to paediatrics and could be adapted for other disciplines