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The relationship between context and health inequalities: Europe and Portugal as case studies
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Resumo(s)
As desigualdades socioeconómicas na saúde têm sido observadas há séculos por todo o mundo. Décadas de investigação identificaram múltiplos fatores que determinam estas desigualdades, como educação ou emprego. Recentemente, o foco da investigação sobre desigualdades em saúde mudou de determinantes individuais para determinantes contextuais, como as características físicas e sociais do ambiente. No entanto, a investigação sobre os determinantes contextuais depara-se com a ausência de uma base teórica sobre como estes determinantes influenciam a saúde. Portugal, sendo um dos
países Europeus mais desiguais, tanto em rendimento como em saúde, é um caso de estudo interessante para o estudo das desigualdades em saúde. Esta tese procura contribuir para a compreensão do impacto dos determinantes contextuais na saúde e na sua distribuição, utilizando Portugal e a Europa como casos de estudo.
Para cumprir este objetivo, foram selecionados três determinantes contextuais – capital social, regimes de bem-estar e alterações macroeconómicas – e os seus efeitos sobre a saúde e sobre as desigualdades em saúde foram explorados. Fora utilizados dados
transversais do European Social Survey para analisar a associação entre capital social e saúde auto-declarada em países Europeus entre 2002 e 2012. A mesma base de dados foi utilizada para analisar a associação entre a mobilidade social e saúde auto-declarada em seis tipos de regimes de bem-estar Europeus. Estas análises utilizaram regressões logísticas multinível. Para analisar evidência sobre desigualdades socioeconómicas na saúde em Portugal depois de 2000 foi efetuada uma revisão sistemática da literatura.
Dados transversais do European Union Survey on Income and Living Conditions foram utilizados para analisar alterações da desigualdade nas limitações em saúde em Portugal entre 2004 e 2014, tendo em conta as alterações macroeconómicas no País. Nesta análise, foram utilizados o índice de concentração e regressões logísticas múltiplas.
O capital social contextual estava associado com pior saúde auto-declarada em indivíduos com pouca confiança interpessoal, influenciando assim a distribuição da saúde. Regimes de bem-estar Europeus estavam associados com a magnitude do impacto da mobilidade social na saúde. A revisão sistemática mostrou que o estudo dos determinantes contextuais em Portugal ainda é incomum. Alterações macroeconómicas em Portugal influenciaram a saúde e a sua distribuição na última década.
Com base nestes resultados, foi delineado um quadro conceptual sobre a influência do contexto na saúde da população e na sua distribuição. O quadro conceptual distingue claramente entre um mecanismo que influencia a saúde da população e outro que influencia a sua distribuição. Este quadro pode ser utilizado como base de análises
futuras para clarificar os mecanismos pelos quais o contexto influencia a saúde e as desigualdades em saúde. Pode também apoiar decisões sobre políticas que procurem influenciar a saúde da população e reduzir as desigualdades em saúde.
Apesar das suas limitações, este trabalho produz evidência sobre os determinantes socioeconómicos da saúde em Portugal e sobre o impacto que o contexto pode ter nestes determinantes e nas desigualdades em saúde. O quadro conceptual proposto poderá
avançar o debate sobre a influência do contexto na saúde e na sua distribuição.
Socioeconomic inequalities in health have been observed for centuries throughout the world. Decades of research have identified multiple factors that determine these inequalities, such as education or employment. More recently, the focus of research in health inequalities shifted from individual to contextual determinants, such as physical and social characteristics of the environment. However, research on contextual determinants has been undermined by the absence of a theoretical basis to explain how these determinants influence health outcomes. Portugal is an interesting case study as it is one of the most unequal European countries both in income and health inequality, with limited academic and political attention to the topic. This dissertation aims to contribute to the understanding of how contextual characteristics can impact population health and health distribution, using Portugal and Europe as case studies. To achieve its aim, this research selected three contextual determinants – social capital, welfare regimes, and macroeconomic changes – and explored their effect on health and health inequalities. Cross-sectional data from the European Social Survey was used to analyse how social capital was associated with self-assessed health in European countries between 2002 and 2012. The same database was used to analyse the association between social mobility and self-assessed health in six welfare regime types in Europe. These analyses used multilevel logistic regressions. A systematic review of the literature was done to collect and analyse evidence about socioeconomic health inequalities in Portugal after 2000. Cross-sectional data from the European Union Survey on Income and Living Conditions was used to analyse how inequalities in health limitations changed in Portugal between 2004 and 2014, in light of important macroeconomic changes in the country. For this analysis, the concentration index was calculated and a multiple logistic regression model was run for each year. Contextual social capital was found to have an effect on individuals with low interpersonal trust, thus influencing health distribution. Welfare regime types were associated with the magnitude of the impact of social mobility on health. The systematic review showed that the study of contextual determinants of health inequalities is still uncommon in Portugal. Finally, important contextual changes in Portugal over the last decade seem to have influenced health and its distribution in the country. Drawing on the findings from these analyses, a conceptual framework was outlined, summarising how context influences population health and health distribution. The framework draws a clear distinction between a mechanism that leads to changes in population health, and another mechanism that leads to changes in health distribution. This framework can be used as a basis for future empirical research, helping clarify the mechanisms by which context influences health and health inequalities. It can also support policies seeking to influence population health and health inequalities. Despite its limitations, this work provides evidence on the social determinants of health in Portugal and on the impact that contextual characteristics can have on these determinants and on health inequalities. The proposed conceptual framework will hopefully further the debate on how context can influence population health and health distribution.
Socioeconomic inequalities in health have been observed for centuries throughout the world. Decades of research have identified multiple factors that determine these inequalities, such as education or employment. More recently, the focus of research in health inequalities shifted from individual to contextual determinants, such as physical and social characteristics of the environment. However, research on contextual determinants has been undermined by the absence of a theoretical basis to explain how these determinants influence health outcomes. Portugal is an interesting case study as it is one of the most unequal European countries both in income and health inequality, with limited academic and political attention to the topic. This dissertation aims to contribute to the understanding of how contextual characteristics can impact population health and health distribution, using Portugal and Europe as case studies. To achieve its aim, this research selected three contextual determinants – social capital, welfare regimes, and macroeconomic changes – and explored their effect on health and health inequalities. Cross-sectional data from the European Social Survey was used to analyse how social capital was associated with self-assessed health in European countries between 2002 and 2012. The same database was used to analyse the association between social mobility and self-assessed health in six welfare regime types in Europe. These analyses used multilevel logistic regressions. A systematic review of the literature was done to collect and analyse evidence about socioeconomic health inequalities in Portugal after 2000. Cross-sectional data from the European Union Survey on Income and Living Conditions was used to analyse how inequalities in health limitations changed in Portugal between 2004 and 2014, in light of important macroeconomic changes in the country. For this analysis, the concentration index was calculated and a multiple logistic regression model was run for each year. Contextual social capital was found to have an effect on individuals with low interpersonal trust, thus influencing health distribution. Welfare regime types were associated with the magnitude of the impact of social mobility on health. The systematic review showed that the study of contextual determinants of health inequalities is still uncommon in Portugal. Finally, important contextual changes in Portugal over the last decade seem to have influenced health and its distribution in the country. Drawing on the findings from these analyses, a conceptual framework was outlined, summarising how context influences population health and health distribution. The framework draws a clear distinction between a mechanism that leads to changes in population health, and another mechanism that leads to changes in health distribution. This framework can be used as a basis for future empirical research, helping clarify the mechanisms by which context influences health and health inequalities. It can also support policies seeking to influence population health and health inequalities. Despite its limitations, this work provides evidence on the social determinants of health in Portugal and on the impact that contextual characteristics can have on these determinants and on health inequalities. The proposed conceptual framework will hopefully further the debate on how context can influence population health and health distribution.
Descrição
Palavras-chave
Saúde pública Prevenção Desigualdade em saúde Factores socioeconómicos Contexto social Portugal Europa
Contexto Educativo
Citação
Editora
Instituto de Higiene e medicina Tropical