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Chapter 1 the Ses and Health Gradient a Brief Review of the Literature

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An economic perspective on the causal explanations for the socioeconomic inequalities in health

Una perspectiva económica sobre las explicaciones causales de las desigualdades socioeconómicas en materia de salud

Uma perspectiva econômica da explicação causal para as desigualdades socioeconômicas em saúde

ABSTRACT

Socioeconomic inequality, or the socioeconomic status (SES) gradient, is arguably one of the nearly-studied phenomena in wellness. The gradient in health is apparent in objective and subjective measures, across virtually all countries, and is evident at individual and population levels. There is no longer much debate over the relationship betwixt SES and health. However, exact causal pathways remain elusive. Advocating for strong policy to reduce or eliminate the SES-health gradient necessitates understanding the causal pathways, from intervention to outcome. While economists are not convinced that there is a clear enough understanding of the causal pathways of the SES-wellness gradient, they take produced a substantial body of work from which to motility forwards. The article briefly discusses the theoretical underpinnings used by economists every bit a basis for the report of the causal pathways for the health slope. That presentation is followed by a concise overview of some of the evidence that economists accept produced. The paper concludes with a discussion of how current economic evidence may be used to assistance policymakers abet for interventions to limit the SES gradient in noncommunicable diseases.

Keywords
Health inequalities; economics

RESUMEN

La desigualdad socioeconómica, o el gradiente según la situación socioeconómica, es posiblemente uno de los fenómenos más estudiados en el campo de la salud. El gradiente de la salud es evidente en mediciones objetivas y subjetivas, en prácticamente todos los países y tanto a nivel individual como poblacional. Ya no se debate mucho la relación entre la situación socioeconómica y la salud. Sin embargo, las vías causales exactas siguen siendo difíciles de definir. A fin de promover políticas enérgicas que reduzcan o eliminen el gradiente socioeconómico de la salud, es necesario entender las vías causales, de la intervención al resultado. Si bien los economistas no están convencidos de que se conozcan suficientemente las vías causales del gradiente socioeconómico de la salud, han producido un volumen sustancial de trabajo a partir del cual avanzar. En este artículo se comentan brevemente los fundamentos teóricos usados por los economistas como base para estudiar las vías causales del gradiente de salud. Luego se brinda un panorama conciso de algunos de los datos científicos generados por los economistas. El artículo concluye con una discusión de cómo pueden usarse los datos científicos económicos actuales para ayudar a los responsables de formular políticas a proponer intervenciones que limiten el gradiente socioeconómico en materia de enfermedades no transmisibles.

Palabras clave
Desigualdades en la salud; economía

RESUMO

A desigualdade socioeconômica, ou o gradiente socioeconômico, é possivelmente um dos fenômenos mais estudados em saúde. O gradiente em saúde é evidente nas medidas objetivas due east subjetivas em praticamente todos os países e é evidente ao nível practise indivíduo eastward de população. Já não existe muito contend sobre a relação entre nível socioeconômico e saúde, mas as exatas vias causais continuam mal definidas. Defender uma firme política para reduzir ou eliminar o gradiente socioeconômico em saúde requer conhecer every bit vias causais, da intervenção ao resultado. Por não estarem convencidos de que existe um entendimento claro razoável das vias causais do gradiente socioeconômico em saúde, os economistas produziram um volume substancial de estudos que servem de base. O artigo aborda resumidamente bone princípios teóricos para embasar o estudo das vias causais practise gradiente em saúde e apresenta de forma concisa o panorama das evidências geradas pelos economistas. Por fim, se discute como as evidências econômicas atuais podem ser empregadas para ajudar os responsáveis pelas políticas a defender intervenções visando reduzir o gradiente socioeconômico nas doenças não transmissíveis.

Palavras-chave
Desigualdades em saúde; economia

Socioeconomic inequality, or the socioeconomic status (SES) gradient is, arguably, one of the most studied phenomena in health. The gradient in health is credible in objective and subjective measures ( ane 1. Marmot M, Ryff CD, Bumpass LL, Shipley Grand, Marks NF. Social inequalities in health: side by side questions and converging evidence. Soc Sci Med. 1997;44(6):901-10. ), across virtually all countries ( 2 2. Evans Due west, Wolfe B, Adler N. The SES and wellness gradient: a cursory review of the literature. In: Wolfe B, Evans Westward, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:i-37. ), and is axiomatic at private and population levels. There is no longer much contend over the relationship betwixt SES and health. However, exact causal pathways remain elusive ( ii 2. Evans W, Wolfe B, Adler N. The SES and health slope: a cursory review of the literature. In: Wolfe B, Evans Due west, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:1-37. – iv 4. Stowasser T, Heiss F, McFadden D, Winter J. "Salubrious, wealthy, and wise?" Revisited: an analysis of the causal pathways from socioeconomic status to health. (Working Paper No. 17273). Cambridge, Massachusetts: National Bureau of Economic Research; 2011. ). Advocating for potent policy to reduce or eliminate the SES-health gradient necessitates understanding the causal pathways ( 2 2. Evans Westward, Wolfe B, Adler Northward. The SES and health gradient: a cursory review of the literature. In: Wolfe B, Evans W, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:1-37. ) from intervention to issue. Economists are not convinced that at that place is a clear enough understanding of the causal pathways of the SES-wellness gradient, just they have produced a substantial body of work from which to motion forward.

Evans, Wolfe, and Adler ( two 2. Evans W, Wolfe B, Adler North. The SES and health gradient: a brief review of the literature. In: Wolfe B, Evans Westward, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:1-37. ) present a cursory merely first-class review of the prove amassed by economists on the relationship between income and health, including discussing some advantages of alternative proxies for SES (e.1000., income, wealth, occupation, and educational activity) and each proxy's usefulness in identifying the elusive causal associations between SES and health. They point out that, in general, education levels are established relatively early on in life and thus may be less influenced by health than other proxies and are therefore a better proxy. According to Deaton ( 5 five. Deaton A. Health, income, and inequality. (NBER Reporter: Research Summary Spring; 2003). Available from: http://www.nber.org/reporter/spring03/health.html Accessed 21 August 2017.
http://www.nber.org/reporter/spring03/he... ), many economists have attempted to tie the SES gradient in wellness to pedagogy (man capital). Simply put, more than-educated people better understand their health, wellness information, and health care systems, and they are more productive at using available resources to generate health ( 6 6. Grossman M. On the concept of health capital and the demand for wellness. J Polit Econ. 1972;80(2):223-55. ). Higher levels of human capital lead to higher incomes and more than consumption. The interaction between better health knowledge and income increases the consumption of healthy inputs, such equally nutritious food, exercise, and advisable health care—thus leading to better health.

Moreover, higher pedagogy has been linked to fewer negative health behaviors, such every bit smoking, sedentary lifestyle, poor nutritional condition, and obesity. The relationship between didactics and health behaviors, particularly negative ones, and health has become a focus in the search for causality ( 7 7. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Health Econ. 2010; 29:1–28. , 8 8. Tubeuf S, Jusot F, Bricard D. Mediating role of instruction and lifestyles in the relationship between early-life conditions and health: evidence from the 1958 British cohort. Wellness Econ. 2012;21(S1):129–50. ). Notwithstanding, researchers oftentimes find that the health behaviors pathway accounts for only a proportion of the SES variation in wellness. For example, Tubeuf et al. ( 8 8. Tubeuf S, Jusot F, Bricard D. Mediating role of pedagogy and lifestyles in the human relationship between early on-life atmospheric condition and health: evidence from the 1958 British cohort. Health Econ. 2012;21(S1):129–50. ) and Brunello et al. ( 9 9. Brunello Yard, Fort M, Schneeweis N, Winter-Ebmer R. The causal outcome of education on health: What is the role of wellness behaviors? (Give-and-take Newspaper No. 5944). Bonn: Institute of Labor Economics; 2011. ) find that lifestyle factors explicate about i-third of the health variation. Given the issues, economists' attempts to identify a causal pathway between income and/or education and wellness have resulted in mixed results ( two 2. Evans West, Wolfe B, Adler Due north. The SES and health gradient: a brief review of the literature. In: Wolfe B, Evans Due west, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:ane-37. – 5 5. Deaton A. Wellness, income, and inequality. (NBER Reporter: Research Summary Spring; 2003). Available from: http://www.nber.org/reporter/spring03/health.html Accessed 21 August 2017.
http://world wide web.nber.org/reporter/spring03/he... , nine 9. Brunello G, Fort Thou, Schneeweis N, Winter-Ebmer R. The causal consequence of education on health: What is the part of health behaviors? (Discussion Paper No. 5944). Bonn: Institute of Labor Economic science; 2011. , 10 10. Grossman K. Instruction and nonmarket outcomes. In: Hanushek EA, Welch F. Handbook of the economics of teaching. Volume one. Amsterdam: Elsevier; 2006:577-633. ).

The difficulty in demonstrating causal links intensifies because reverse causality and endogeneity are detail problems in the study of the SES-wellness human relationship ( 5 five. Deaton A. Health, income, and inequality. (NBER Reporter: Research Summary Leap; 2003). Available from: http://www.nber.org/reporter/spring03/health.html Accessed 21 Baronial 2017.
http://world wide web.nber.org/reporter/spring03/he... ). Equally previously discussed ( 7 7. Cutler DM, Lleras-Muney A. Agreement differences in health behaviors by education. J Wellness Econ. 2010; 29:1–28. , 8 8. Tubeuf S, Jusot F, Bricard D. Mediating part of education and lifestyles in the relationship between early on-life conditions and health: testify from the 1958 British cohort. Health Econ. 2012;21(S1):129–50. ), the main premise is that higher SES leads to improve wellness. Still, information technology is possible that the causal path runs from health to SES. For example, lower wellness status could restrict instruction, human capital accumulation, and/or labor market participation, thus leading to lower education and/or income (opposite causality). Alternatively, unobserved characteristics may influence both pedagogy and health decisions, so the effects of one on the other cannot be estimated consistently ( 5 5. Deaton A. Health, income, and inequality. (NBER Reporter: Inquiry Summary Spring; 2003). Available from: http://www.nber.org/reporter/spring03/wellness.html Accessed 21 August 2017.
http://world wide web.nber.org/reporter/spring03/he... , 11 11. Adda J, Lechene V. On the identification of the consequence of smoking on mortality. (Working paper No. CWP13/04). London: Centre for Microdata Methods and Do, Institute for Fiscal Studies; 2004 ). Economists have attempted to identify unobserved characteristics inside socioeconomic strata that may bulldoze health differences ( 8 8. Tubeuf S, Jusot F, Bricard D. Mediating role of education and lifestyles in the relationship betwixt early-life conditions and health: prove from the 1958 British accomplice. Health Econ. 2012;21(S1):129–50. , 12 12. Vikesh A, Behrman JR, Spector T. Does more schooling amend health outcomes and health related behaviors? Evidence from U.Thou. twins. Econ Educ Rev. 2013;35:134-48. – fifteen 15. Meghir C, Palme G, Simeonova E. Education, health and mortality: prove from a social experiment. (Working Paper No. 17932). Cambridge, Massachusetts: National Bureau of Economical Research: 2012. ). These characteristics include access to health intendance (utilization is typically assessed with surveys that have no measure of when care was needed and not received, or the reasons); differential productivity in the apply of health data or wellness care; differential vulnerability; such ecology factors as pollution or chemical exposure ( 13 13. Cutler DM, Lange F, Meara Eastward, Richards S, Ruhm CJ. Explaining the rise in educational gradients in mortality. J Health Econ. 2010;30:1174-87. – fifteen 15. Meghir C, Palme One thousand, Simeonova E. Education, health and bloodshed: evidence from a social experiment. (Working Newspaper No. 17932). Cambridge, Massachusetts: National Agency of Economic Enquiry: 2012. ); and cumulative effects (i.e., individuals from lower socioeconomic situations experience more health shocks than those from higher socioeconomic situations) ( 16 xvi. Seabrook JA, Avison WR. Socioeconomic status and cumulative disadvantage processes across the life class: implications for health outcomes. Tin can Rev Soc. 2012;49(i):50–68. – 20 20. Evans GW, Kim P. Multiple risk exposure as a potential explanatory mechanism for the socioeconomic status–health slope. NY Acad Sci. 2010;1186:174–89. ).

This short newspaper presents a cursory discussion of the theoretical underpinnings used by economists equally a basis for the study of the causal pathways for the health gradient. This is followed by an overview of some of the widely cited economic research in this area. The overview is organized by the causal pathways that have been studied: SES → health; SES → wellness behaviors → wellness; health → SES (opposite causality); and unobserved factors → SES and health (unobserved heterogeneity). There is next a cursory discussion of evidence available in the Americas and for noncommunicable diseases (NCDs) specifically, followed by some conclusions and policy give-and-take.

The paper is not meant to be an exhaustive or systematic review, but instead to provide an overview of some of the well-cited, highly regarded evidence that economists have produced. The overview covers studies examining secondary information using diverse methodologies, too as reviews of such studies. It is anticipated that this presentation of economical evidence will lead readers to investigate further how current methodologies may be used to develop new frameworks and expand the utilize of economical theories and econometric tools to effectively advocate for the prevention of NCDs, including developing policies within and beyond the health sector in the Americas and other world regions.

THEORETICAL UNDERPINNINGS

Standard economic theory tells us that individuals cull to consume goods and services based on their preferences, upkeep constraints (eastward.g., dissimilar incomes and prices), and beliefs in the impact of their deportment (if the assumption of full data is not invoked). About economic theories on the relationship betwixt SES (typically proxied by income and/or instruction) and wellness expand the standard theory based on one of the seminal papers written by Becker ( 21 21. Becker GS. Investment in human capital: a theoretical analysis. J Polit Econ. 1962 Oct 1;70(5, Part 2):9-49. , 22 22. Becker GS. A theory of the allocation of time. Econ J. 1965;75 (299):493–517. ), Grossman ( 6 6. Grossman M. On the concept of health capital and the demand for health. J Polit Econ. 1972;lxxx(ii):223-55. ), and/or Rosenzweig and Schultz ( 23 23. Rosenzweig MR, Schultz TP. Estimating a household product role: heterogeneity and the demand for health inputs, and their effects on birth weight. J Polit Econ. 1983;91(5):723-46. ). The authors add together differences in productivity, household production, and unobserved characteristics to the standard framework. Basically, the models maximize utility (happiness, well-beingness), which is created past consuming goods and services (G&S) and health. The Yard&Southward may positively influence health (healthy food, etc.) or negatively do so (cigarettes, etc.). As well as purchasing final goods in the market (e.m., a healthy meal), individuals may utilize their time to catechumen (via a production process) appurtenances purchased in the market place (intermediate goods (east.thou., ingredients to brand the healthy meal)) into final consumption goods (the healthy meal) and health. The ease of the production process (productivity) depends on the private'southward level of educational activity and other unobserved factors (e.g., family background, genetics, intelligence). The corporeality of goods purchased in the market and the time bachelor for production depends on prices, wages, labor market place participation, income, and wealth.

Although empirical studies frequently avoid laying out explicit theoretical models, the general framework underpins much of the research. The theoretical models ( vi 6. Grossman M. On the concept of health capital and the demand for health. J Polit Econ. 1972;fourscore(2):223-55. , 21 21. Becker GS. Investment in homo upper-case letter: a theoretical assay. J Polit Econ. 1962 Oct ane;70(v, Office 2):9-49. – 23 23. Rosenzweig MR, Schultz TP. Estimating a household product role: heterogeneity and the need for wellness inputs, and their effects on birth weight. J Polit Econ. 1983;91(5):723-46. ) implicitly direct researchers to focus on the pathways betwixt SES, health inputs (east.g., health care, health insurance (if public wellness insurance is not available to all), health behaviors (positive and negative), and unobserved factors (unobserved heterogeneity (e.g., genetics, intelligence, environment, etc.)), and health outcomes. Expansive literatures have evolved on the SES → wellness pathways, including the SES → health behaviors → health pathway.

PATHWAYS INVOLVING THE SOCIOECONOMIC Condition (SES) Slope

SES → health

Excellent overviews on the relationship between SES (income ( 2 2. Evans W, Wolfe B, Adler Northward. The SES and wellness gradient: a brief review of the literature. In: Wolfe B, Evans W, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:i-37. ) and education ( 10 x. Grossman G. Educational activity and nonmarket outcomes. In: Hanushek EA, Welch F. Handbook of the economics of education. Volume 1. Amsterdam: Elsevier; 2006:577-633. , 14 14. Cutler DM, Glaeser EL, Rosen AB. Is the U.s.a. population behaving healthier? In: Brown JR, Leibman J, Wise D, eds. Social Security policy in a changing environment. Cambridge, Massachusetts: National Agency of Economical Research; 2009:423-42. )) and health are available. Evans, Wolfe, and Adler ( 2 2. Evans W, Wolfe B, Adler N. The SES and health gradient: a brief review of the literature. In: Wolfe B, Evans W, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:ane-37. ) conclude that "despite much work on the mechanisms that lie behind the gradient ( 24 24. Adler N, Stewart J, eds. The biology of disadvantage: socioeconomic condition and health. New York: Wiley-Blackwell; 2010. ), we cannot fully account for the observed disparities in wellness across income." As previously stated, education has been used equally a more robust instrument for SES than income ( 2 ii. Evans W, Wolfe B, Adler N. The SES and health gradient: a brief review of the literature. In: Wolfe B, Evans Due west, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:1-37. ). An often-cited paper by Cutler et al. ( 13 13. Cutler DM, Lange F, Meara E, Richards S, Ruhm CJ. Explaining the rise in educational gradients in mortality. J Health Econ. 2010;30:1174-87. ) uses multiple nationally representative cross-sections of survey and authoritative information from the Usa of America to prove that for not-Hispanic whites the educational gradient in mortality (from cancer and cardiovascular disease (CVD)) has grown over fourth dimension and that this cannot be explained past changes in primal behavioral risk factors. The returns to didactics (conditional on health behaviors) and changes in returns to health behaviors are important and increasing, and they are stronger for males than females. The affect of smoking strengthened over time for both men and women, equally have the consequences of severe obesity for females. Results suggest that complete emptying of disparities in behavioral risks across education groups would probable not decrease the differentials in mortality essentially (approximately 7% to 25%). Although influential, the study uses cross-sectional data. This blazon of information is strongly criticized in the literature for its inability to place causality.

The shortcomings of cross-sectional information propelled the employ of natural experiments to study causal relationships. Natural experiments occur when circumstances outside the control of the researcher (due east.g., the introduction of a public policy such as compulsory schooling reform) lead a subset of a population to be differentially exposed to a hypothesized causal factor (i.e., education). Meaning differences in outcomes across exposed and unexposed populations can indicate a causal path between the exposure and the outcome. A noun review of the schooling reforms literature is offered by Meghir et al. ( 15 15. Meghir C, Palme 1000, Simeonova East. Educational activity, health and bloodshed: prove from a social experiment. (Working Paper No. 17932). Cambridge, Massachusetts: National Agency of Economic Enquiry: 2012. ). A stiff positive relationship between didactics and health is found in the United States in information from the early on to mid-1900s ( 25 25. Lleras-Muney A. The relationship betwixt education and adult bloodshed in the U.s.. Rev Econ Stud. 2005;72(one):189-221. ). Notwithstanding, the same information produces more muted results when land-specific time trends are included with the policy reforms or when larger datasets (which identify individuals rather than cohorts) are employed ( 26 26. Bhash Thou. Does education improve wellness? A reexamination of the prove from compulsory schooling laws. Econ Perspect. 2008;32(2):2-xvi. ). Given that results differ when using information from the same country, information technology is not surprising that conclusions examining compulsory schooling reforms are mixed when using data from different countries and time periods. Positive results are found in Denmark ( 27 27. Arendt J. Does pedagogy cause amend health? A panel data analysis using schoolhouse reforms for identification. Econ Educ Rev. 2005;24(two):149-60. ) and England and Northern Ireland ( 28 28. Oreopoulos P. Estimating average and local average handling effects of education when compulsory schooling laws really thing. Am Econ Rev. 2006;96(1):152-75. ) past some researchers, while others find negligible or negative results in Sweden ( 15 xv. Meghir C, Palme M, Simeonova Due east. Instruction, health and mortality: evidence from a social experiment. (Working Paper No. 17932). Cambridge, Massachusetts: National Agency of Economic Research: 2012. ) and the United kingdom ( 29 29. Clark D, Royer H. The event of education on adult health and mortality: evidence from Great britain. (Working Paper No. 16013). Cambridge, Massachusetts: National Agency of Economic Research; 2010. ). Results are strongly dependent on where and when the data originate (mayhap pointing to differences in institutions across countries, sample sizes, and populations ( 15 15. Meghir C, Palme M, Simeonova E. Education, health and bloodshed: evidence from a social experiment. (Working Paper No. 17932). Cambridge, Massachusetts: National Bureau of Economic Enquiry: 2012. )) and the empirical analyses employed ( 26 26. Bhash M. Does educational activity improve wellness? A reexamination of the evidence from compulsory schooling laws. Econ Perspect. 2008;32(ii):two-16. ).

Cross-land comparisons also produced inconsistent results. Using countries with changes in mandatory leaving age equally an instrumental variable in a dynamic health equation, Brunello et al. ( nine nine. Brunello G, Fort One thousand, Schneeweis N, Winter-Ebmer R. The causal result of teaching on wellness: What is the role of health behaviors? (Discussion Paper No. 5944). Bonn: Institute of Labor Economics; 2011. ) find an additional twelvemonth of education decreases cocky-reported poor wellness past 7% for females and by 3% for males. Health behaviors explain approximately i-quarter to one-half of the upshot. Moreover, Cutler and Lleras-Muney ( 6 6. Grossman Chiliad. On the concept of health uppercase and the demand for health. J Polit Econ. 1972;eighty(2):223-55. ) show that income, health insurance, and family background explain well-nigh one-tertiary of the didactics slope in health, and that cognitive ability explains nearly ane-5th of information technology. They demonstrate a pathway running from instruction to cognitive ability to healthier behaviors to wellness. Discounting, run a risk aversion, or fourth dimension preferences account for none of the gradients in health behaviors. In that location is some prove that the social environs (healthier for the better educated) accounts for about one-tenth of the education/health gradient.

The mixed results found in the literature spurred researchers to identify better ways of identification. Studies using samples of monozygotic (identical) twins to control for unobserved factors (due east.g., family and genetic backgrounds shared completely by identical twins) were idea to be a solution. These studies suggest that causal impacts of schooling on health outcomes and behaviors are much smaller than suggested by other studies (although some of the studies were criticized for small sample sizes). Amin, Behrman, and Spector ( 30 30. Vikesh A, Behrman JR, Spector TD. Does more than schooling improve health outcomes and health related behaviors? Evidence from U.K. twins. Econ Educ Rev. 2013;35:134-48. ) used multiple twin registries in the United states of america and found, like many other studies, that schooling is significantly associated with numerous wellness outcomes and behaviors. However, no causal relationship could be identified between schooling and amend health behaviors afterward controlling for unobserved factors. Twin studies take found that higher education is positively related to self-reported health ( 10 10. Grossman M. Education and nonmarket outcomes. In: Hanushek EA, Welch F. Handbook of the economics of instruction. Volume 1. Amsterdam: Elsevier; 2006:577-633. , 31 31. Lundborg P. The wellness returns to educational activity: What can nosotros learn from twins? (Discussion Paper No. 3399). Bonn: Constitute for the Written report of Labor; 2008. ) and negatively related to the number of chronic conditions ( 31 31. Lundborg P. The health returns to education: What tin we larn from twins? (Discussion Paper No. 3399). Bonn: Institute for the Study of Labor; 2008. ), merely causality has been more than difficult to assign.

A multidisciplinary review of the literature ( 32 32. Kawachi I. Adler NE, Dow WH. Money, schooling, and wellness: mechanisms and causal evidence. Ann NY Acad Sci. 2010;1186:56-68. ), which includes many of the studies discussed in this paper, claims that there is a sufficient body of evidence to suggest that schooling is causally related to improvements in health outcomes, and that raising the incomes of the poor leads to improvement in their health outcomes. However, that review likewise notes that the findings are crude and that more specific questions need to exist asked, such as what type of didactics matters for wellness or whether there is a difference betwixt the wellness impacts of temporary income shocks versus changes in long-term income. Other reviews of the testify tend to support the need for farther testify.

Health → SES (reverse causality)

At that place is a plethora of literature on the relationship between childhood health and outcomes in later life. The hypothesis is that the causal pathway runs from kid (poor) health to (lower) SES. Households with lower SES cannot, or do not know how to, provide proper nutrition to mothers and children, leading to poor health. Children in poor health (ofttimes measured by superlative or low birthweight) tend to obtain lower levels of education and worse labor market outcomes over their life ( 7 seven. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Health Econ. 2010; 29:1–28. , viii 8. Tubeuf Southward, Jusot F, Bricard D. Mediating role of didactics and lifestyles in the relationship between early-life conditions and health: testify from the 1958 British cohort. Health Econ. 2012;21(S1):129–50. , 33 33. Case A, Fertig A, Paxson C. The lasting bear on of babyhood health and circumstance. J Health Econ. 2005;24(2):365-89. , 34 34. Example A, Paxson C. Causes and consequences of early on-life health. Demogr. 2010;47(S1):S65–S85. ). In a natural experiment, Almond ( 35 35. Almond D. Is the 1918 influenza pandemic over? Long-term effects of in utero influenza exposure in the post-1940 U.S. population. J Polit Econ. 2006;114(4):672-712. ) showed potent negative education, health (physical disability), income, and SES effects for cohorts in utero during the 1918 influenza pandemic compared to those conceived earlier or after the pandemic. In a British cohort study, children born with low weights were found to pass fewer qualifying exams ( 33 33. Case A, Fertig A, Paxson C. The lasting impact of childhood health and circumstance. J Wellness Econ. 2005;24(2):365-89. ). Studies on twins in Norway ( 36 36. Blackness S, Devereux P, Salvanes KG. From the cradle to the labor market? The issue of birth weight on adult outcomes. Q J Econ. 2007;122(1):409-39. ) and the U.s.a. ( 37 37. Behrman, JR, Rosenzweig MR. Returns to birthweight. Rev Econ Stat. 2004;86(ii):586-601. ) showed that depression birthweights led to significantly lower height, IQs, education, and earnings. Height was also a strong predictor of obtaining higher education in Sweden ( 38 38. Magnusson PKE, Rasmussen F, Gyllensten UB. Height at historic period 18 years is a strong predictor of attained education later in life: cohort written report of over 950 000 Swedish men. Inter J Epidemiol. 2006;35(3):658-63. ) and the Us ( 34 34. Case A, Paxson C. Causes and consequences of early on-life wellness. Demogr. 2010;47(S1):S65–S85. ). This empirical evidence suggests that role of the positive gradient between education and health originates in the effect of childhood wellness on educational attainment. The quantitative importance is still questioned, but it appears that reverse causality tin can explain, at virtually, a minor proportion of the observed slope ( 7 vii. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Wellness Econ. 2010; 29:1–28. ).

Other hypotheses regarding reverse causality in the SES-health gradient be just are less well examined than the child health hypotheses. Individuals in poor health may have lower productivity and higher rates of absenteeism, which results in lower labor force participation, wages, and incomes. Studies in this area tend to measure the consequences of specific diseases on productivity or amass economic consequences of productivity loss ( 39 39. Brown H, Pagan SJA, Bastidad E. The impact of diabetes on employment: genetic IVs in a bivariate probit. Health Econ. 2005;14:537–44. , 40 xl. Oliva-Moreno J. Loss of labour productivity caused by disease and health bug: What is the magnitude of its effect on Espana'south economic system? Eur J Wellness Econ. 2012;13(five):605-xiv. ). An alternate explanation is that those with lower life expectancies (poor wellness) may have higher discount rates. They thus invest less in their time to come and subsequently have lower educational activity, man capital, and income, as well equally higher levels of risky behavior ( 41 41. Chao LW, Szrek H, Pereira NS, Pauly MV. Fourth dimension preference and its human relationship with historic period, health, and survival probability. Judgm Decis Mak. 2009;four(1):1–xix. – 43 43. Suen RM. Fourth dimension preference and the distributions of wealth and income. Econ Inq. 2014;52(1):364–81. ). Finally, it is possible that high wellness intendance costs due to poor health atomic number 82 to lower disposable incomes, particularly in the absence of wellness insurance ( 44 44. Caswell KJ, Waidmann T, Blumberg LJ. Financial burden of medical out-of-pocket spending by state and the implications of the 2014 Medicaid expansions. Enquiry. 2013;50(three):177–201. ).

Unobserved factors → SES and health (unobserved heterogeneity)

As demonstrated in the motion to twin studies to examine the education-wellness link, failure to identify a causal link betwixt SES and wellness behaviors and/or health led researchers to the caption that unobserved characteristics inside socioeconomic strata bulldoze wellness differences ( 9 9. Brunello M, Fort Thou, Schneeweis North, Winter-Ebmer R. The causal consequence of education on health: What is the role of health behaviors? (Discussion Paper No. 5944). Bonn: Institute of Labor Economic science; 2011. , thirteen xiii. Cutler DM, Lange F, Meara Eastward, Richards S, Ruhm CJ. Explaining the ascension in educational gradients in bloodshed. J Health Econ. 2010;30:1174-87. , xv fifteen. Meghir C, Palme M, Simeonova E. Didactics, health and bloodshed: bear witness from a social experiment. (Working Newspaper No. 17932). Cambridge, Massachusetts: National Agency of Economic Enquiry: 2012. , xxx thirty. Vikesh A, Behrman JR, Spector TD. Does more schooling ameliorate health outcomes and health related behaviors? Evidence from U.K. twins. Econ Educ Rev. 2013;35:134-48. , 31 31. Lundborg P. The health returns to education: What tin can we acquire from twins? (Discussion Newspaper No. 3399). Bonn: Found for the Report of Labor; 2008. ). The unobserved differences are thought to include genetics, family background, admission to health care, differential productivity in the use of health information or health care, differential vulnerability, differential exposure to ecology factors (risky work, unsafe neighborhoods, chemical exposure, air and water quality, etc.) ( seven seven. Cutler DM, Lleras-Muney A. Understanding differences in health behaviors by education. J Wellness Econ. 2010; 29:1–28. , 16 sixteen. Seabrook JA, Avison WR. Socioeconomic status and cumulative disadvantage processes beyond the life form: implications for health outcomes. Can Rev Soc. 2012;49(1):50–68. ), and cumulative effects (e.1000., individuals, specially children, from lower socioeconomic situations experience more wellness shocks than those from higher socioeconomic situations) ( 16 xvi. Seabrook JA, Avison WR. Socioeconomic status and cumulative disadvantage processes across the life grade: implications for wellness outcomes. Can Rev Soc. 2012;49(1):50–68. – twenty 20. Evans GW, Kim P. Multiple take a chance exposure equally a potential explanatory mechanism for the socioeconomic status–health gradient. NY Acad Sci. 2010;1186:174–89. , 33 33. Case A, Fertig A, Paxson C. The lasting impact of childhood health and circumstance. J Health Econ. 2005;24(2):365-89. , 34 34. Example A, Paxson C. Causes and consequences of early-life health. Demogr. 2010;47(S1):S65–S85. ). Once more, no conclusive evidence has been produced, and where evidence for a causal link is found, the affect seems minor.

THE SES Gradient IN Health AND THE AMERICAS AND NONCOMMUNICABLE DISEASES

Few economic studies were identified that focused directly on the SES slope in NCDs in full general or in the Americas. Meghir et al. ( 15 15. Meghir C, Palme G, Simeonova Due east. Education, health and mortality: evidence from a social experiment. (Working Paper No. 17932). Cambridge, Massachusetts: National Bureau of Economic Inquiry: 2012. ) did examine cancer and CVD mortality rates, only the report population was non-Hispanic whites in the United states. A recent overview of systematic reviews ( 45 45. Sommer I, Griebler U, Mahlknecht P, Thaler K, Bouskill K, Gartlehner Thousand, Mendis S. Socioeconomic inequalities in not-infectious disease and their adventure factors: an overview of systematic reviews. BMC Public Health. 2015;xv:914 ) institute evidence that supports an association between socioeconomic inequalities and NCDs and risk factors for NCDs, just the overview noted that the evidence is incomplete and is express by poor methodological quality.

Most well-known studies in the literature employ data from the United States or countries of Europe, due to the availability of good-quality information, research capacity, and expert publication outlets. The few studies identified that focus on countries in Latin America or the Caribbean tend to be descriptive in nature and are less well known ( 46 46. Almeida Yard, Sarti FM. Measuring evolution of income-related inequalities in health and health care utilization in selected Latin American and Caribbean countries. Rev Panam Salud Publica. 2013;33(ii):83-9. – 49 49. Vásquez F, Paraje G, Estay M. Income-related inequality in wellness and health intendance utilization in Chile, 2000-2009. Rev Panam Salud Publica. 2013;33(2):98-106. ). An exception is the evaluation of a Mexican program called Progresa (and later Oportunidades), which provided cash transfers to families if their children attended school or medical appointments to receive preventive care (due east.g., vaccinations) ( fifty l. Fawley BW, Juvenal L. United mexican states'due south Oportunidades program fails to make the Grade in NYC. Reg Econ. 2010;18(iii):10–1. ). The assessment found that doubling cash transfers was related to a decrease in stunting, a decrease in body mass index, a lower prevalence of existence overweight, and an increase in height for age ( fifty 50. Fawley BW, Juvenal L. United mexican states's Oportunidades program fails to make the Grade in NYC. Reg Econ. 2010;18(iii):10–1. ). The experiment was copied in some areas of the United States, simply the results were non duplicated ( 2 2. Evans Westward, Wolfe B, Adler N. The SES and health gradient: a cursory review of the literature. In: Wolfe B, Evans Due west, Seeman TE, eds. The biological consequences of socioeconomic inequalities. New York: Russell Sage Foundation; 2012:1-37. , 50 50. Fawley BW, Juvenal L. Mexico's Oportunidades programme fails to make the Grade in NYC. Reg Econ. 2010;18(iii):10–1. ).

Health data are bachelor in the Americas. Almeida and Sarti ( 46 46. Almeida Thousand, Sarti FM. Measuring evolution of income-related inequalities in health and health care utilization in selected Latin American and Caribbean countries. Rev Panam Salud Publica. 2013;33(2):83-9. ) discuss cross-sectional datasets collected in Brazil, Republic of chile, Colombia, Jamaica, United mexican states, and Peru that could be used to movement the study of health and health intendance inequities forrard in the Americas. An analysis of the Costa Rican Longevity and Healthy Aging Written report surprisingly establish an SES gradient in cocky-reported wellness status and good for you years of life but an inverse gradient in CVD and mortality ( 51 51. Rosero-Bixby L, Dow WH. Surprising SES gradients in mortality, health, and biomarkers in a Latin American population of adults. J Gerontol B Psychol Sci Soc Sci. 2009;64B(1):105–17. ). This led the authors to conclude that modernistic negative health behaviors among high-SES groups in Costa rica may exist reversing CVD risks and thus bloodshed gamble past SES groups.

DISCUSSION

The SES gradient in health is, arguably, ane of the most-studied and well-accustomed phenomena in wellness. It is credible in objective and subjective measures, beyond virtually all countries, and information technology is evident at individual and population levels. There is no longer much debate over the human relationship between SES and wellness. However, the literature presented in this piece indicates that exact causal pathways remain elusive. The most promising show suggests that kid health influences education and thus outcomes in later life (reverse causality), although the magnitude of the result is still questioned. As well, family background, including income, influences kid health, with effects accumulating over the lifespan (income → wellness). Withal, despite more than than two decades of research, investigators do non fully understand what causes the observed disparities in health across SES. The lack of consistent results across studies could be due to differences in data (including sample sizes), methodologies, institutional settings, unobservables, or a combination of these factors. What is axiomatic is that there is probable no 1 cistron that drives the gradient. Income, teaching, health care, health behaviors, and other factors accept impacts on the gradient. However, the measured impacts of individual factors are ofttimes not as large as anticipated.

Economists in public wellness intervention enquiry are attempting to design research that tin examine how multiple intertwined factors (e.g., education, income, the experience of poverty, available health care resources, etc.) produce individual and interacted health impacts. However, at this bespeak, in light of the mixed results in the literature, policymakers are left with the tough conclusion of which, if whatsoever, of the factors might produce desired results in their populations, given the bachelor resource.

Researchers often phone call for governments and policymakers to assist in the provision of ameliorate longitudinal data to further the research, either through funding or by assuasive access to administrative data. Longitudinal data would, for example, help to identify better measures of permanent income, of long-term versus transitory shocks to income and health, and of short-term versus long-term experiences of poverty. It is now possible and becoming less expensive to collect better information on what historically were unobservables (e.g., genetic or family characteristics). These types of improvements in data may help in the identification of the elusive causal pathways of the health gradient.

Making administrative information (such equally registries of mortality, cancer, CVD, and other diseases) bachelor and linking these databases to other administrative databases (such every bit taxation and teaching files) might provide much improved data to written report the links betwixt socioeconomic condition and NCDs. Wellness and sociodemographic data are being collected in some countries of Latin America and the Caribbean, and some interesting experiments have been undertaken (e.g., Progresa/Oportunidades).

Building interest in funding more experiments and/or collecting better data would help increment the research chapters in the Americas and elsewhere. In plow, better research capacity could provide several benefits. It would enable researchers to apply the economical theories and methodologies that have been used in many of the studies cited in this piece. It would aid to identify new methods to detect the causal pathways needed to address SES inequalities in health. And, information technology would provide policymakers with the data needed to make evidenced-based policy decisions in the Americas and elsewhere.

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Publication Dates

  • Publication in this collection
    16 July 2018

History

  • Received
    xv Oct 2017
  • Accustomed
    22 Jan 2018

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