Change in the level of health inequalities in the years 2003 and 2010

Benković, Vanesa. (2017). Change in the level of health inequalities in the years 2003 and 2010. PhD Thesis. Filozofski fakultet u Zagrebu, Department of Sociology.
(Poslijediplomski doktorski studij sociologije) [mentor Štulhofer, Aleksandar].

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Abstract

This thesis discusses the phenomenon of health inequalities. The focus is on the differences in health inequalities at two points in time considered on the basis of self-assessed health (dependent variable) and four independent dimensions: psychological characteristics, social connectedness, socioeconomic status (SES), and access to health care. The objective was to research the influence of economic and psychosocial inequalities on the health status and access to health care as relating to citizens of Croatia aged between 25 and 65, and to compare the connections between health and social inequalities at two points in time (in the years 2003 and 2010). Moreover, the thesis examines the social determination of health, that is, the connections between health and individual and group psychosocial characteristics (optimism, locus of control, and social connectedness) as well as with structural limitations (socioeconomic status and access to health care). The results of two surveys were used in the thesis: the HZA 2003 (Croatian Health Poll 2003) and the NUZ 2010 (Health Inequalities 2010). In the first part of the analysis, the results of the two surveys are compared, while the second addresses only the results of the NUZ 2010. The idea was to examine the changes in health inequalities at two points in time and proceed to explore in more detail the relationships between the independent dimensions – the SES, access to health care, social connectedness, and psychological characteristics – and the dependent variable of health on the sample used in the NUZ 2010. Additionally, the thesis explores the structure and gender specificity of the relations among the dimensions. The HZA 2003 survey was conducted in the year 2003 on a sample of 8,806 respondents. For the purpose of this thesis, a target sample was selected consisting of respondents aged between 25 and 65 (N=5,143) to allow sample comparison, and variables consistent with the variables in the NUZ 2010 were selected. The NUZ 2010 survey was conducted in the year 2010 using poll method on a multi-stage stratified probability sample of male and female population aged between 25 and 65 (N=1,026). The first half of the survey form includes health indicators (including body weight index) and indicators of health problems, lifestyle components (smoking, alcohol consumption, physical activity), and indicators of use of health services and associated barriers to health care access (distance from health care facilities, financial costs, etc). The second half of the survey form examines personal characteristics (happiness, satisfaction, optimism, and locus of control), social connectedness (networks and personal social capital), and the sociodemographic characteristics of the participants, their parents, and the households in which they live. Using exploratory factor analysis in the construction of composite variables, the obtained data were analyzed in various procedures that included descriptive statistics, bivariate analyses (one-way analysis of variance -- ANOVA), multivariate linear regression analysis, and hierarchy regression analysis. The hierarchy approach was used to establish the specific contribution of the SES following control of sociodemographic characteristics (age and gender) in the interpreted variance of the health variable as well as to differentiate among the contributions of the SES, social connectedness, access to health care, and the psychological characteristics to health variability. No statistically significant difference in the health level of men and women was established, while age was established to have a negative connection to health in both tested years, as had been expected. Educational status was a significant predictor of health both in 2003 and in 2010. A finding that was to some extent unexpected was the connection between marital status and health – the respondents who were single reported a considerably higher level of health in both surveys than did the married, divorced, and widowed respondents, which is accounted for by the intervening influence of age. The findings showed a considerably lower health level in persons with the lowest income than in those with higher income. The first hypothesis, which assumed that the connection between the SES and health would be greater in 2010 than in 2003, was not supported. The data indicate that there is no difference between the connection of the SES and health in 2003 and that in 2010. The testing of the second hypothesis, which assumed that a connection existed between access to health care and the SES in the sample from the year 2010, led to the result that showed a low but significant connection between the SES and health care access, which primarily relates to physical access to health care services. One of the explanations for this lies in the fact that access to family physicians in Croatia is mostly quite good, while another can be attributed to the fact that the part of the population with a higher SES considers physical distance "more accessible" if they own a vehicle or have resources available with which to compensate for the distance. Moreover, the question is to what extent the sample included persons in locations with the greatest distance to health care services, which are some of the Croatian islands and inland. Furthermore, elderly persons (over the age of 65), for whom a stronger connection would be expected, were not included in the surveys. As regards the third hypothesis, the results of the 2010 survey showed a statistically significant positive connection between the variables of psychological characteristics and social connectedness on the one hand and the dimension of health on the other. The relationship between health and the independent dimensions of psychological characteristics, social connectedness, access to health care and the SES was tested in a health model. It was shown that psychological characteristics and social conectedness as well as SES and health care access were statistically significantly positively correlated to health – the higher the socioeconomic status, the better the social conectedness; with more positive psychological characteristics access to health care services is better, and so is health. However, dimensions of psychological characteristics and social connectedness (or support) showed better connection and explained health better than SES and access to health care dimensions. Access to health care was shown to have a somewhat weaker connection to health in relation to the other three dimensions, which is assumed to be partly due to the connectedness of the SES and health. The gender specificity of this result showed that the SES and psychological characteristics were significant for both women and men, while social connectedness, psychological characteristics, and health care access were significant only for men. The connection between health and psychological characteristics was somewhat stronger in women. The thesis on statistically significant but weak positive connection between health care access and the SES was confirmed. There is no difference between the impact of the SES on health in the year 2003 and that in the year 2010. A statistically significant positive connection between the dimensions of psychological characteristics and social connectedness was established, with age proving to be significantly connected to the dimension of psychological characteristics. The positive connection between the SES, social connectedness, and psychological characteristics on the one hand and the health variable on the other hand is statistically more significant than the connection between health care access and health. As far as gender structure is concerned, the SES and psychological characteristics were shown to be more significant predictors of health in women, while social connectedness and health care access were more important for men. Practical implications indicate that, in intervention planning, a distinction should be made between individual health determinants and group health determinants, that is, structural health determinants. This would facilitate a better intervention focus, that is, a better assessment of which measures influence which type of determinant and, very importantly, including both. It is recommended that further studies analyze in more detail the gender specificity of the relationship between disease and social connectedness. Recommendations for further research also include smaller, specific studies focused on the relationships among the elements included in this thesis, in particularly vulnerable groups such as single-parent families, as well as on comparison of data on connections between health and the SES on the one hand and the population parameters used in this thesis on the other.

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