From understanding to reducing health disparities: a model-based evaluation

描述（由申请人提供）：解决低社会经济地位和高社会经济地位（SES）群体在健康方面的巨大差异，需要详细了解社会经济地位（如教育、收入和财富）与健康（包括残疾和死亡率）之间复杂的相互作用。近年来，在描述整个生命周期中社会经济状况与健康的各个方面之间的关系以及了解因果途径的相对重要性和方向方面取得了进展。然而，尽管在知识方面取得了这些进步，但对产生观察到的因果关系的许多机制知之甚少。由于缺乏一个全面的理论框架来解释经验事实，进展受到阻碍。因此，毫不奇怪，最近的文献综述指出缺乏这样一个统一的理论，并强调了发展一个统一理论的重要性。我们最近为建立一个统一的理论框架作出了重大努力，以分析整个生命周期的健康和社会经济地位轨迹。我们的理论框架旨在将ses -健康梯度理解为理性（但受约束）个人行为的结果。结构模型包含许多潜在的机制，可以解释由SES造成的健康差异。特别重要的似乎是生活方式因素（预防性护理、健康和不健康的消费）、工作条件（与工作有关的健康压力）1、治疗性护理以及健康对工作的制约作用。需要进行经验检验以区分重要机制和不太重要的机制。本研究的目标是：(i)从这个框架中得出新的、可测试的预测；（ii）使用来自美国和欧洲国家的现有面板数据来检验这些预测。这些测试的目的不仅是建立合理的因果关系，而且要评估产生因果关系的潜在机制；（三）将估计的模型与国际制度变化相结合，使政策和决策者了解减少卫生差距的备选公共政策的相对有效性。该研究的具体目的是：1)利用生活方式和工作的结构模型，提高我们对造成健康方面社会经济差异的机制的理解；2)利用迄今为止最丰富的面板数据，运用结构模型对生活方式和工作相关健康压力的重要性进行实证评估；3)评估健康诱发的劳动力退出对健康差异的贡献；4)评估制度和公共政策对产生/缓和健康差距的影响。1与工作有关的健康压力的概念可以广泛地解释，其范围从体力工作条件（例如，繁重的劳动）到工作的社会心理方面（例如，地位低、控制有限、重复工作等）。这里的概念是，它可以包括对健康有害的工作的任何方面，因此与工资溢价有关（相对于不会对健康产生有害影响的想象情况）。

DESCRIPTION (provided by applicant): Addressing the substantial disparity in health between low and high socioeconomic status (SES) groups requires a detailed understanding of the complex interaction between dimensions of SES (such as, education, income and wealth) and those of health (including disability and mortality). Progress has been made in recent years in characterizing the relationships between the various dimensions of SES and health over the lifecycle and in understanding the relative importance and directions of causal pathways. Yet, despite these advances in knowledge little is known about many of the mechanisms that produce the observed causal relations. Progress is hampered by the lack of a comprehensive theoretical framework to interpret empirical facts. It is no surprise then that recent reviews of the literature point to the absence of such a unifying theory and emphasize the importance of developing one. We have recently made substantial efforts toward the development of a unified theoretical framework for analyzing health and socioeconomic status trajectories over the lifecycle. Our theoretical framework aims to understand the SES-health gradient as the outcome of rational (but constrained) individual behavior. The structural model contains many potential mechanisms that could explain disparities in health by SES. Of particular importance appear to be lifestyle factors (preventive care, healthy and unhealthy consumption), work conditions (job-related health stress)1, curative care and the constraining effect of health on work. Empirical testing is needed to distinguish important from less important mechanisms. The objectives of this research are (i) to derive new, testable predictions from this framework; (ii) to test these predictions using existing panel data from the US and European countries. The aim of these tests is not only to establish plausible causality but to evaluate the underlying mechanisms that produce the causal relationships; and (iii) to couple the estimated models with international variation in institutions to inform policy and decision makers about the relative effectiveness of alternative public policies to reduce disparities in health. The specific aims of the proposed research are to: 1) improve our understanding of mechanisms responsible for socioeconomic disparities in health using a structural model of lifestyle and work; 2) use the structural model to empirically assess the importance of lifestyle and job-related health stress with the richest panel data available to date; 3) evaluate the contribution of health-induced labor-force withdrawal to health disparities; and 4) assess the effects of institutions and public policies on creating/moderating health disparities. 1 The concept of job-related health stress can be interpreted broadly and can range from physical working conditions (e.g., hard labor) to psychosocial aspects of work (e.g., low status, limited control, repetitive work, etc). The notion here is that it can include any aspect of work that is detrimental to health and as such is associated with a wage premium (relative to an imaginary situation where there would not be a detrimental affect on health). PUBLIC HEALTH RELEVANCE: Without a detailed understanding of the causes of the substantial disparities in health between low and high socioeconomic status groups, policies aimed at reducing such disparities are likely to be ineffective. We have recently made substantial efforts toward the development of a structural model that allows for many potential mechanisms that could explain disparities in health by SES over the lifecycle. The objectives of this research are (i) to derive new, testable predictions from this framework, (ii) to test these predictions using existing panel data from the US and European countries, and (iii) to use the estimated models and international variation to inform policy and decision makers about the relative effectiveness of alternative public policies to reduce disparities in health.