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

描述（由申请人提供）：解决低和高社会经济地位（SES）群体之间健康的巨大差距需要详细了解SES（如教育，收入和财富）和健康（包括残疾和死亡率）维度之间的复杂相互作用。近年来，在描述生命周期中社会经济地位和健康的各个方面之间的关系以及理解因果途径的相对重要性和方向方面取得了进展。 然而，尽管在知识上取得了这些进展，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。 最近，我们已经做出了巨大的努力，发展了一个统一的理论框架，用于分析生命周期中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。结构模型包含了许多潜在的机制，可以解释健康的SES的差距。特别重要的似乎是生活方式因素（预防保健、健康和不健康的消费）、工作条件（与工作有关的健康压力）1、治疗保健和健康对工作的制约作用。需要进行实证检验，以区分重要机制和次要机制。 本研究的目标是：（i）从这个框架中得出新的、可检验的预测;（ii）使用美国和欧洲国家现有的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，但要评估产生因果关系的基本机制;和（iii）耦合的估计模型与国际变化的机构，告知政策和决策者的相对有效性的替代公共政策，以减少健康的差距。 本研究的具体目的是：1）使用生活方式和工作的结构模型，提高我们对健康社会经济差异机制的理解; 2）使用结构模型，以迄今为止最丰富的面板数据，实证评估生活方式和工作相关健康压力的重要性; 3）评估健康导致的劳动力退出对健康差异的贡献;（4）评估机构和公共政策对创造/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义地解释，可以从物理工作条件（例如，艰苦劳动）到工作的社会心理方面（例如，低地位、有限的控制、重复性工作等）。这里的概念是，它可以包括工作的任何方面，这是有害的健康，因此与工资溢价（相对于一个想象的情况下，不会有一个有害的健康影响）。 公共卫生相关性：如果不详细了解社会经济地位低和社会经济地位高的群体之间在健康方面存在巨大差距的原因，旨在减少这种差距的政策就可能无效。我们最近已经做出了大量的努力，发展一个结构模型，允许许多潜在的机制，可以解释在生命周期中的SES的健康差异。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）使用美国和欧洲国家现有的面板数据来测试这些预测，以及（iii）使用估计的模型和国际变化来告知政策和决策者关于替代公共政策的相对有效性，以减少健康差距。

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.