JECH136333 740..745

Welfare states are important determinants of health. Comparative social epidemiology has almost invariably concluded that population health is enhanced by the relatively generous and universal welfare provision of the Scandinavian countries. However, most international studies of socioeconomic inequalities in health have thrown up something of a public health ‘puzzle’ as the Scandinavian welfare states do not, as would generally be expected, have the smallest health inequalities. This essay outlines and interrogates this puzzle by drawing upon existing theories of health inequalitiesdartefact, selection, culturalebehavioural, materialist, psychosocial and life coursedto generate some theoretical insights. It discusses the limits of these theories in respect to crossnational research; it questions the focus and normative paradigm underpinning contemporary comparative health inequalities research; and it considers the future of comparative social epidemiology. BACKGROUND It is now widely acknowledged that welfare states are important determinants of health as they mediate the social determinants of health. Welfare state provision varies extensively, but typologies have been put forward to categorise them into distinctive typesdwelfare state regimes. Welfare state regimes have increasingly been used within social epidemiology to analyse cross-national differences in population health. These studies have almost invariably concluded that population health is enhanced by the relatively generous and universal welfare provision of the Social Democratic Scandinavian countries, especially when contrasted to the Anglo-Saxon welfare states. The different types of welfare state and their constituent countries are described in box 1. However, in contrast to their comparatively strong performance in terms of overall health, data from most, but not all, of the recent comparative studies of health inequalities in the general population suggest that the Scandinavian welfare states do not have the smallest health inequalities. For example, Mackenbach et al’s Europe wide study of inequalities in mortality found ‘no evidence for systematically smaller inequalities in health in countries in northern Europe (Scandinavia)’. Indeed, relative inequalities in mortality were smaller in the Southern (Italy, Spain, Portugal) and Bismarckian (Netherlands, Belgium, Germany, France) countries. Data are provided from three other example studies of health inequalities in Europe in table 1. 12 Given the higher levels of social expenditure in the Scandinavian welfare states, the smaller income inequalities, and the commitment to equality underpinning the Social Democratic welfare model in Scandinavia, it has long been something of a ‘puzzle’ in public health as to why the Scandinavian countries do not have the smallest health inequalities. This essay draws upon the theories of health inequalities to scrutinise this puzzle. THEORETICAL INSIGHTS ON COMPARATIVE HEALTH INEQUALITIES Box 2 outlines the main theories of health inequalities. These are commonly used to explain socioeconomic health inequalities within countries. In this paper, they are applied to crossnational differences in the magnitude of socioeconomic health inequalities and used to offer insights into the puzzle as to why health inequalities are not the smallest in the Scandinavian welfare states. Artefact The artefact explanation questions the existence of health inequalities, considering them to be a mere artefact of data collection and measurement (box 2). Applying it to the issue of comparative health inequalities leads to the conclusion that the ‘public health puzzle’dof why health inequalities are not the smallest in the Scandinavian countriesdis not in fact a real puzzle, but simply the result of the data and methods used. Certainly, the application of different indicators of social inequality (eg, income, occupation and education) and the use of different data sets has produced divergent results (see table 1). Different crossnational patterns also emerge in terms of the different ways in which specific indicators of inequality are calculated. For example, studies of educational inequalities can compare those with average years of education to those with 1SD below the national average or the difference between those with no education or only primary education compared with those with tertiary education (box 2). There are also more general issues in terms of making cross-national comparisons of health inequalities as it is not clear whether the bottom groups are the same in each country and whether their composition changes over time. 22 The use of relative or absolute measures of health inequalities is also an important issue (see ‘Discussion’ section). There is of course another clear measurement problem, which is the use of ‘welfare state regimes’, a concept that assumes a homogeneous approach to welfare provision within and between the countries of any particular regime type. 23 Correspondence to Professor Clare Bambra, Department of Geography, Wolfson Research Institute, Queen’s Campus, Durham University, Stockton on Tees, TS17 6BH, UK; clare.bambra@durham.ac. uk Accepted 23 May 2011 Published Online First 20 June 2011 740 J Epidemiol Community Health 2011;65:740e745. doi:10.1136/jech.2011.136333 Essay on M arch 6, 2021 by gest. P rocted by coright. httpjech.bm jcom / J E pdem ol C om m unity H elth: frst pulished as 10.1136. 2011.136333 on 20 Jne 211. D ow nladed fom Health selection The health selection approach asserts that health determines socioeconomic class status rather than socioeconomic class determining health (box 2). This would imply that the social consequences of ill health would need to be greater in the Scandinavian countries and that people who have ill health are more likely to be concentrated in the lower socioeconomic groups. Instinctively, such direct selection seems unlikely given the extensive employment protection for people with ill health within the Nordic countries and their comparatively high replacement rates for people out of the labour market due to sickness or disability. Selection is also considered to be more influential in respect to income-related inequalities than educational ones and so it is unlikely to explain the results of the comparative studies of educational inequalities in health. Culture and behaviour The culturalebehavioural approach asserts that the link between socioeconomic class and health is a result of differences between socioeconomic classes in terms of their health-related behaviour (box 2). In terms of physical activity and diet, there is no evidence of larger inequalities in the Scandinavian countries, at least as measured by educational inequalities in obesity. However, socioeconomic inequalities in smoking are much higher in the Nordic countries than in the other welfare state regimes. 14 Similarly, inequalities in deaths from cardiovascular disease are higher in the Scandinavian countries (except Denmark) as compared with other European countries. This, it is argued, is because the Scandinavian countries are at a very mature stage of the smoking epidemic with the majority of smoking behaviour concentrated in the least educated groups. Box 1 Welfare state regimes