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

说明(由申请人提供)：要解决低社会经济地位群体和高社会经济地位群体之间的健康差距，需要详细了解社会经济地位各方面(如教育、收入和财富)和健康方面(包括残疾和死亡率)之间的复杂相互作用。近年来，在刻画生命周期中SES的不同维度与健康之间的关系以及理解因果路径的相对重要性和方向方面取得了进展。然而，尽管知识取得了这些进步，但人们对产生所观察到的因果关系的许多机制知之甚少。由于缺乏解释经验事实的全面理论框架，进展受到阻碍。因此，最近的文献评论指出缺乏这样一个统一的理论并强调发展一个理论的重要性也就不足为奇了。我们最近为开发一个统一的理论框架来分析生命周期中的健康和社会经济状况轨迹做出了实质性的努力。我们的理论框架旨在将SES-健康梯度理解为理性(但受限制的)个人行为的结果。结构模型包含许多潜在的机制，可以解释社会经济状况在健康方面的差异。特别重要的似乎是生活方式因素(预防护理、健康和不健康消费)、工作条件(与工作有关的健康压力)1、治疗护理以及健康对工作的制约作用。需要进行实证检验，以区分重要的机制和次要的机制。这项研究的目标是(I)从这个框架中得出新的、可检验的预测；(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确定可信的因果关系，而且评估产生因果关系的潜在机制；以及(Iii)将估计模型与机构的国际差异结合起来，向政策制定者和决策者通报替代公共政策减少健康差距的相对有效性。拟议研究的具体目的是：1)使用生活方式和工作的结构模型，提高我们对造成健康社会经济差异的机制的理解；2)使用结构模型，通过迄今可获得的最丰富的小组数据，实证评估生活方式和与工作相关的健康压力的重要性；3)评估健康导致的劳动力撤出对健康差异的贡献；以及4)评估机构和公共政策在创造/缓解健康差异方面的影响。1与工作相关的健康压力的概念可以被广泛地解释，范围从体力工作条件(例如，艰苦劳动)到工作的心理社会方面(例如，低地位、有限的控制力、重复性工作等)。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).