Who loses more? Identifying the relationship between hospitalization and income loss: prediction of hospitalization duration and differences of gender and employment status.

BACKGROUND: The major determinants of health and well-being include wider socio-economic and political responses to poverty alleviation. To data, however, South Korea has no related social protection policies to replace income loss or prevent non-preferable health conditions for workers. In particular, there are several differences in social protection policies by gender or occupational groups. This study aimed to investigate how hospitalization affects income loss among workers in South Korea. METHODS: The study sample included 4876 Korean workers who responded to the Korean Welfare Panel Study (KoWePS) for all eight years from 2009 to 2016. We conducted a receiver operating characteristics (ROC) analysis to determine the cut-off point for the length of hospitalization that corresponded to the greatest loss of income. We used panel multi-linear regression to examine the relationship between hospitalization and income loss by gender and employment arrangement. RESULTS: The greatest income loss for women in non-standard employment and self-employed men was observed when the length of hospitalization was seven days or less. When they were hospitalized for more than 14 days, income loss also occurred among men in non-standard employment. In addition, when workers were hospitalized for more than 14 days, the impact of the loss of income was felt into the subsequent year. CONCLUSION: Non-standard and self-employed workers, and even female standard workers, are typically excluded from public insurance coverage in South Korea, and social security is insufficient when they are injured. To protect workers from the vicious circle of the poverty-health trap, national social protections such as sickness benefits are needed.

Evaluating the impact of the nationwide public-private mix (PPM) program for tuberculosis under National Health Insurance in South Korea: A difference in differences analysis.

BACKGROUND: Public-private mix (PPM) programs on tuberculosis (TB) have a critical role in engaging and integrating the private sector into the national TB control efforts in order to meet the End TB Strategy targets. South Korea's PPM program can provide important insights on the long-term impact and policy gaps in the development and expansion of PPM as a nationwide program. METHODS AND FINDINGS: Healthcare is privatized in South Korea, and a majority (80.3% in 2009) of TB patients sought care in the private sector. Since 2009, South Korea has rapidly expanded its PPM program coverage under the National Health Insurance (NHI) scheme as a formal national program with dedicated PPM nurses managing TB patients in both the private and public sectors. Using the difference in differences (DID) analytic framework, we compared relative changes in TB treatment outcomes-treatment success (TS) and loss to follow-up (LTFU)-in the private and public sector between the 2009 and 2014 TB patient cohorts. Propensity score matching (PSM) using the kernel method was done to adjust for imbalances in the covariates between the 2 population cohorts. The 2009 cohort included 6,195 (63.0% male, 37.0% female; mean age: 42.1) and 27,396 (56.1% male, 43.9% female; mean age: 45.7) TB patients in the public and private sectors, respectively. The 2014 cohort included 2,803 (63.2% male, 36.8% female; mean age: 50.1) and 29,988 (56.5% male, 43.5% female; mean age: 54.7) patients. In both the private and public sectors, the proportion of patients with transfer history decreased (public: 23.8% to 21.7% and private: 20.8% to 17.6%), and bacteriological confirmed disease increased (public: 48.9% to 62.3% and private: 48.8% to 58.1%) in 2014 compared to 2009. After expanding nationwide PPM, absolute TS rates improved by 9.10% (87.5% to 93.4%) and by 13.6% (from 70.3% to 83.9%) in the public and private sectors. Relative to the public, the private saw 4.1% (95% confidence interval [CI] 2.9% to 5.3%, p-value < 0.001) and -8.7% (95% CI -9.7% to -7.7%, p-value <0.001) higher rates of improvement in TS and reduction in LTFU. Treatment outcomes did not improve in patients who experienced at least 1 transfer during their TB treatment. Study limitations include non-longitudinal nature of our original dataset, inability to assess the regional disparities, and verify PPM program's impact on TB mortality. CONCLUSIONS: We found that the nationwide scale-up of the PPM program was associated with improvements in TB treatment outcomes in the private sector in South Korea. Centralized financial governance and regulatory mechanisms were integral in facilitating the integration of highly diverse South Korean private sector into the national TB control program and scaling up of the PPM intervention nationwide. However, TB care gaps continued to exist for patients who transferred at least once during their treatment. These programmatic gaps may be improved through reducing administrative hurdles and making programmatic amendments that can help facilitate management TB patients between institutions and healthcare sectors, as well as across administrative regions.

The influence of welfare state factors on nursing professionalization and nursing human resources: A time-series cross-sectional analysis, 2000-2015.

AIM: The aim of this study was to examine the relationship between welfare states and nursing professionalization indicators. DESIGN: We used a time-series, cross-sectional design. The analysis covered 16 years and 22 countries: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, South Korea, Spain, Sweden, Switzerland, United Kingdom, and the United States, allocated to five welfare state regimes: Social Democratic, Christian Democratic, Liberal, Authoritarian Conservative, and Confucian. METHODS: We used fixed-effects linear regression models and conducted Prais-Winsten regressions with panel-corrected standard errors, including a first-order autocorrelation correction. We applied the Amelia II multiple imputation strategy to replace missing observations. Data were collected from March-December 2017 and subsequently updated from August-September 2018. RESULTS: Our findings highlight positive connections between the regulated nurse and nurse graduate ratios and welfare state measures of education, health, and family policy. In addition, both outcome variables had averages that differed among welfare state regimes, the lowest being in Authoritarian Conservative regimes. CONCLUSION: Additional country-level and international comparative research is needed to further study the impact of a wide range of structural political and economic determinants of nursing professionalization. IMPACT: We examined the effects of welfare state characteristics on nursing professionalization indicators and found support for the claim that such features affect both the regulated nurse and nurse graduate ratios. These findings could be used to strengthen nursing and the nursing workforce through healthy public policies and increase the accuracy of health human resources forecasting tools.

Association of social deprivation and outdoor air pollution with pulmonary tuberculosis in spatiotemporal analysis.

The objective of this study was to identify the association between social deprivation, outdoor air pollution, and tuberculosis (TB) incidence rate or mortality rate. The study sample comprised 25 districts in Seoul, Korea. We used two public data derived from the Community Health Survey and Seoul Statistics. The geographic information system analysis and random effects Poisson regression were applied to explore the association of social deprivation and air pollution with TB incidence and mortality. An 1 ppb increase in sulfur dioxide (SO2) concentration was significantly associated with the risk of TB incidence (risk ratio [RR] = 1.046, 95% confidence interval [CI]: 1.028, 1.065). An 1 unit increase in the deprivation index was significantly related to a6% increase in the mortality of TB (RR = 1.063, 95% CI: 1.031, 1.097). : Our results imply that social deprivation and air pollution may affect the different TB outcomes. Effective policy-making for TB control should reflect the differing outcomes between TB incidence and mortality.

Nursing professionalization and welfare state policies: A critical review of structural factors influencing the development of nursing and the nursing workforce.

Nursing professionalization is both ongoing and global, being significant not only for the nursing workforce but also for patients and healthcare systems. For this reason, it is important to have an in-depth understanding of this process and the factors that could affect it. This literature review utilizes a welfare state approach to examine macrolevel structural determinants of nursing professionalization, addressing a previously identified gap in this literature, and synthesizes research on the relevance of studying nursing professionalization. The use of a welfare state framework facilitates the understanding that the wider social, economic, and political system exercises significant power over the distribution of resources in a society, providing a glimpse into the complex politics of health and health care. The findings shed light on structural factors outside of nursing, such as country-level education, health, labor market, and gender policies that could impact the process of professionalization and thus could be utilized to strengthen nursing through facilitating increased professionalization levels. Addressing gender inequalities and other structural determinants of nursing professionalization could contribute to achieving health equity and could benefit health systems through enhanced availability, skill-level, and sustainability of nursing human resources, improved and efficient access to care, improved patient outcomes, and cost savings.

Social class and mental health: testing exploitation as a relational determinant of depression.

This study tests whether social class exploitation operates as a relational mechanism that generates mental health inequalities in the nursing home industry. We ask, does social class exploitation (i.e., the acquisition of economic benefits from the labor of those who are dominated) have a systematic and predictable impact on depression among nursing assistants? Using cross-sectional data from 868 nursing assistants employed in 50 nursing homes in three U.S. states, we measure social class exploitation as "ownership type" (private for-profit, private not-for-profit, and public) and "managerial domination" (labor relations violations, perceptions of labor-management conflict). Depression is assessed using the original and revised versions of the Center for Epidemiologic Studies Depression Scale (CES-D and CESD-R). Using two-level logistic regressions, we find that private for-profit ownership and higher managerial domination are predictive of depression among nursing assistants even after adjustment for potential confounders and mediators. Our findings confirm the theoretical and empirical value of applying a social class approach to understanding how mental health inequalities are generated through exploitative mechanisms. Ownership type and managerial domination appear to affect depression through social relations that generate mental health inequalities through the process of acquiring profits, controlling production, supervising and monitoring labor, and enforcing disciplinary sanctions.

Complementarities or contradictions? Scoping the health dimensions of "flexicurity" labor market policies.

Flexicurity, or the integration of labor market flexibility with social security and active labor market policies, has figured prominently in economic and social policy discussions in Europe since the mid-1990s. Such policies are designed to transcend traditional labor-capital conflicts and to form a mutually supportive nexus of flexibility and security within a climate of intensified competition and rapid technological change. International bodies have marketed flexicurity as an innovative win-win strategy for employers and workers alike, commonly citing Denmark and The Netherlands as exemplars of best practice. In this article, we apply a social determinants of health framework to conduct a scoping review of the academic and gray literature to: (a) better understand the empirical associations between flexicurity practices and population health in Denmark and (b) assess the relevance and feasibility of implementing such policies to improve health and reduce health inequalities in Ontario, Canada. Based on 39 studies meeting our full inclusion criteria, preliminary findings suggest that flexicurity is limited as a potential health promotion strategy in Ontario, offers more risks to workers' health than benefits, and requires the strengthening of other social protections before it could be realistically implemented within a Canadian context.

Egalitarian policies and social determinants of health in Bolivarian Venezuela.

In 1999, newly-elected Venezuelan President Hugo Chávez initiated a far-reaching social movement as part of a political project known as the Bolivarian Revolution. Inspired by the democratic ideologies of Simón Bolívar, this movement was committed to reducing intractable inequalities that defined Venezuela's Fourth Republic (1958-1998). Given the ambitious scope of these reforms, Venezuela serves as an instructive example to understand the political context of social inequalities and population health. In this article, we provide a brief overview of the impact of egalitarian policies in Venezuela, stressing: (a) the socialist reforms and social class changes initiated by the Bolivarian Movement; (b) the impact of these reforms and changes on poverty and social determinants of health; (c) the sustainability of economic growth to continue pro-poor policies; and (d) the implications of egalitarian policies for other Latin American countries. The significance and implications of Chávez's achievements are now further underscored given his recent passing, leading one to ask whether political support for Bolivarianism will continue without its revolutionary leader.

Maternal socioeconomic position and inequity in child deaths: An analysis of 2012 South Korean birth cohort of 466,636 children.

Background: Inequalities in child mortality occur via interactions between socio-environmental factors and their constituents. Through childhood developmental stages, we can observe changing patterns of mortality. By investigating these patterns and social inequalities by cause and developmental stage, we aim to gain insights into health policies to reduce and equalize childhood mortality. Methods: Using vital statistics, we examined the Korean birth cohort of 2012, including all children born in 2012 up to five years of age (N = 466,636). The dependent variables were all-cause and cause-specific mortality by developmental stage (i.e., neonatal, post-neonatal, and childhood). A Cox proportional hazard regression model was built to compare child mortality according to maternal education. The distribution of inequalities in cause-specific mortality by child age was calculated using the slope index of inequality (SII). Results: Inequalities in child mortality due to maternal education occur during the neonatal period and increase over time. After adjusting for covariates, the Cox proportional hazard models showed that "injury and external causes" (HR = 2.178; 95% CI = [1.283-3.697]) and "unknown causes" (HR = 2.299; 95% CI = [1.572-3.363]) in the post-neonatal period, and "injury and external causes" (HR = 2.153; 95% CI = [1.347-3.440]) in the childhood period significantly contributed to socioeconomic inequalities in child mortality. For each period, the leading causes of inequality were identified as follows: "congenital" (96.7%) for the neonatal period, "unknown causes" (58.2%) and "injury and external causes" (28.4%) for the post-neonatal period, and "injury and external causes" (56.5%) for the childhood period. Conclusion: We confirmed that the main causes of death in mortality inequality vary according to child age, in accordance with the distinctive context of child development. Strengthening the health system and multisectoral efforts that consider families' and children's needs according to spatial contexts (e.g., home, community) may be necessary to address the social inequalities in child health.

Barriers to knowledge production, knowledge translation, and urban health policy change: ideological, economic, and political considerations.

In this paper, we consider social forces that affect the processes of both knowledge production and knowledge translation in relation to urban health research. First, we briefly review our conceptual model, derived from a social-conflict framework, to outline how unequal power relations and health inequalities are causally linked. Second, we critically discuss ideological, political, and economic barriers that exist within academia that affect knowledge production related to urban health and health inequalities. Third, we broaden the scope of our analysis to examine how the ideological, political, and economic environment beyond the academy creates barriers to health equity policy making. We conclude with some key questions about the role that knowledge translation can possibly play in light of these constraints on research and policy for urban health.

Hierarchical cluster analysis of labour market regulations and population health: a taxonomy of low- and middle-income countries.

BACKGROUND: An important contribution of the social determinants of health perspective has been to inquire about non-medical determinants of population health. Among these, labour market regulations are of vital significance. In this study, we investigate the labour market regulations among low- and middle-income countries (LMICs) and propose a labour market taxonomy to further understand population health in a global context. METHODS: Using Gross National Product per capita, we classify 113 countries into either low-income (n = 71) or middle-income (n = 42) strata. Principal component analysis of three standardized indicators of labour market inequality and poverty is used to construct 2 factor scores. Factor score reliability is evaluated with Cronbach's alpha. Using these scores, we conduct a hierarchical cluster analysis to produce a labour market taxonomy, conduct zero-order correlations, and create box plots to test their associations with adult mortality, healthy life expectancy, infant mortality, maternal mortality, neonatal mortality, under-5 mortality, and years of life lost to communicable and non-communicable diseases. Labour market and health data are retrieved from the International Labour Organization's Key Indicators of Labour Markets and World Health Organization's Statistical Information System. RESULTS: Six labour market clusters emerged: Residual (n = 16), Emerging (n = 16), Informal (n = 10), Post-Communist (n = 18), Less Successful Informal (n = 22), and Insecure (n = 31). Primary findings indicate: (i) labour market poverty and population health is correlated in both LMICs; (ii) association between labour market inequality and health indicators is significant only in low-income countries; (iii) Emerging (e.g., East Asian and Eastern European countries) and Insecure (e.g., sub-Saharan African nations) clusters are the most advantaged and disadvantaged, respectively, with the remaining clusters experiencing levels of population health consistent with their labour market characteristics. CONCLUSIONS: The labour market regulations of LMICs appear to be important social determinant of population health. This study demonstrates the heuristic value of understanding the labour markets of LMICs and their health effects using exploratory taxonomy approaches.

Social class, politics, and the spirit level: why income inequality remains unexplained and unsolved.

Richard Wilkinson and Kate Pickett's latest book, The Spirit Level: Why Equality is Best for Everyone, has caught the attention of academics and policymakers and stimulated debate across the left-right political spectrum. Interest in income inequality has remained unabated since the publication of Wilkinson's previous volume, Unhealthy Societies: The Afflictions of Inequality. While both books detail the negative health effects of income inequality, The Spirit Level expands the scope of its argument to also include social issues. The book, however, deals extensively with the explanation of how income inequality affects individual health. Little attention is given to political and economic explanations on how income inequality is generated in the first place. The volume ends with political solutions that carefully avoid state interventions such as limiting the private sector's role in the production of goods and services (e.g., non-profit sector, employee-ownership schemes). Although well-intentioned, these alternatives are insufficient to significantly reduce the health inequalities generated by contemporary capitalism in wealthy countries, let alone around the world.

Politics, welfare regimes, and population health: controversies and evidence.

In recent years, a research area has emerged within social determinants of health that examines the role of politics, expressed as political traditions/parties and welfare state characteristics, on population health. To better understand and synthesise this growing body of evidence, the present literature review, informed by a political economy of health and welfare regimes framework, located 73 empirical and comparative studies on politics and health, meeting our inclusion criteria in three databases: PubMed (1948-), Sociological Abstracts (1953-), and ISI Web of Science (1900-). We identified two major research programmes, welfare regimes and democracy, and two emerging programmes, political tradition and globalisation. Primary findings include: (1) left and egalitarian political traditions on population health are the most salutary, consistent, and substantial; (2) the health impacts of advanced and liberal democracies are also positive and large; (3) welfare regime studies, primarily conducted among wealthy countries, find that social democratic regimes tend to fare best with absolute health outcomes yet consistently in terms of relative health inequalities; and (4) globalisation defined as dependency indicators such as trade, foreign investment, and national debt is negatively associated with population health. We end by discussing epistemological, theoretical, and methodological issues for consideration for future research.

Work or place? Assessing the concurrent effects of workplace exploitation and area-of-residence economic inequality on individual health.

Building on previous multilevel studies in social epidemiology, this cross-sectional study examines, simultaneously, the contextual effects of workplace exploitation and area-of-residence economic inequality on social inequalities in health among low-income nursing assistants. A total of 868 nursing assistants recruited from 55 nursing homes in Kentucky, Ohio, and West Virginia were surveyed between 1999 and 2001. Using a cross-classified multilevel design, the authors tested the effects of area-of-residence (income inequality and racial segregation), workplace (type of nursing home ownership and managerial pressure), and individual-level (age, gender, race/ethnicity, health insurance, length of employment, social support, type of nursing unit, preexisting psychopathology, physical health, education, and income) variables on health (self-reported health and activity limitations) and behavioral outcomes (alcohol use and caffeine consumption). Findings reveal that overall health was associated with both workplace exploitation and area-of-residence income inequality; area of residence was associated with activity limitations and binge drinking; and workplace exploitation was associated with caffeine consumption. This study explicitly accounts for the multiple contextual structure and effects of economic inequality on health. More work is necessary to replicate the current findings and establish robust conclusions on workplace and area of residence that might help inform interventions.

Class relations and all-cause mortality: a test of Wright's social class scheme using the Barcelona 2000 Health Interview Survey.

The aim of this study is to test the effects of neo-Marxian social class and potential mediators such as labor market position, work organization, material deprivation, and health behaviors on all-cause mortality. The authors use longitudinal data from the Barcelona 2000 Health Interview Survey (N=7526), with follow-up interviews through the municipal census in 2008 (95.97% response rate). Using data on relations of property, organizational power, and education, the study groups social classes according to Wright's scheme: capitalists, petit bourgeoisie, managers, supervisors, and skilled, semi-skilled, and unskilled workers. Findings indicate that social class, measured as relations of control over productive assets, is an important predictor of mortality among working-class men but not women. Workers (hazard ratio = 1.60; 95% confidence interval, 1.10-2.35) but also managers and small employers had a higher risk of death compared with capitalists. The extensive use of conventional gradient measures of social stratification has neglected sociological measures of social class conceptualized as relations of control over productive assets. This concept is capable of explaining how social inequalities are generated. To confirm the protective effect of the capitalist class position and the "contradictory class location hypothesis," additional efforts are needed to properly measure class among low-level supervisors, capitalists, managers, and small employers.

Immigration, employment relations, and health: Developing a research agenda.

BACKGROUND: International migration has emerged as a global issue that has transformed the lives of hundreds of millions of persons. Migrant workers contribute to the economic growth of high-income countries often serving as the labour force performing dangerous, dirty and degrading work that nationals are reluctant to perform. METHODS: Critical examination of the scientific and "grey" literatures on immigration, employment relations and health. RESULTS: Both lay and scientific literatures indicate that public health researchers should be concerned about the health consequences of migration processes. Migrant workers are more represented in dangerous industries and in hazardous jobs, occupations and tasks. They are often hired as labourers in precarious jobs with poverty wages and experience more serious abuse and exploitation at the workplace. Also, analyses document migrant workers' problems of social exclusion, lack of health and safety training, fear of reprisals for demanding better working conditions, linguistic and cultural barriers that minimize the effectiveness of training, incomplete OHS surveillance of foreign workers and difficulty accessing care and compensation when injured. Therefore migrant status can be an important source of occupational health inequalities. CONCLUSIONS: Available evidence shows that the employment conditions and associated work organization of most migrant workers are dangerous to their health. The overall impact of immigration on population health, however, still is poorly understood and many mechanisms, pathways and overall health impact are poorly documented. Current limitations highlight the need to engage in explicit analytical, intervention and policy research.

Employment relations and global health: a typological study of world labor markets.

In this study, the authors investigate the global labor market and employment relations, which are central building blocks of the welfare state; the aim is to propose a global typology of labor markets to explain global inequalities in population health. Countries are categorized into core (21), semi-peripheral (42), and peripheral (71) countries, based on gross national product per capita (Atlas method). Labor market-related variables and factors are then used to generate clusters of countries with principal components and cluster analysis methods. The authors then examine the relationship between the resulting clusters and health outcomes. The clusters of countries are largely geographically defined, each cluster with similar historical background and developmental strategy. However, there are interesting exceptions, which warrant further elaboration. The relationship between health outcomes and clusters largely follows the authors' expectations (except for communicable diseases): more egalitarian labor institutions have better health outcomes. The world system, then, can be divided according to different types of labor markets that are predictive of population health outcomes at each level of economic development. As is the case for health and social policies, variability in labor market characteristics is likely to reflect, in part, the relative strength of a country's political actors.

Case studies on employment-related health inequalities in countries representing different types of labor markets.

The authors selected nine case studies, one country from each cluster of their labor market inequalities typology, to outline the macro-political and economic roots of employment relations and their impacts on health. These countries illustrate variations in labor markets and health, categorized into a global empirical typology. The case studies illustrated that workers' health is significantly connected with labor market characteristics and the welfare system. For a core country, the labor market is characterized by a formal sector. The labor institutions of Sweden traditionally have high union density and collective bargaining coverage and a universal health care system, which correlate closely with positive health, in comparison with Spain and the United States. For a semi-periphery country, the labor market is delineated by a growing informal economy. Although South Korea, Venezuela, and El Salvador provide some social welfare benefits, a high proportion of irregular and informal workers are excluded from these benefits and experience hazardous working conditions that adversely affect their health. Lastly, several countries in the global periphery--China, Nigeria, and Haiti--represent informal work and severe labor market insecurity. In the absence of labor market regulations, the majority of their workers toil in the informal sector in unsafe conditions with inadequate health care.

A macro-level model of employment relations and health inequalities.

The authors develop a macro-social theoretical framework to explain how employment and working conditions affect health inequalities. The theoretical framework represents the social origins and health consequences of various forms of employment conditions. The emphasis is thus on determinants and consequences of employment conditions, not on social determinants of health in general. The framework tries to make sense of the complex link between macro-social power relations among employers, government, and workers' organizations, labor market and social policies, employment and working conditions, and the health of workers. It also suggests further testing of hypothetical causal pathways not covered in the literature. This macro-social theoretical framework might help identify the main "entry points" through which to implement policies and interventions to reduce employment-related health inequalities. The theoretical framework should be approached from a historical perspective.

A micro-level model of employment relations and health inequalities.

Theoretical models are a way of visualizing, in context, the many factors that contribute to inequalities in health. This article presents a model showing the micro-level pathways relating employment and working conditions to health inequalities. A first important (indirect) pathway runs through the unequal distribution of harmful working conditions. Both employment and working conditions tend to be unequally distributed along the same social axes: social class, gender, ethnicity/race, immigration/migration status, territory, and so forth. Underlying mechanisms are exploitation, domination, and discrimination. Material deprivation and economic inequalities constitute a second direct pathway linking (nonstandard) employment conditions to health inequalities. In a third pathway, employment conditions may have an important effect on health inequalities via several psychosocial, behavioral, and physiopathological pathways. Although these several pathways are separated for analytical purposes, they are largely intertwined and, ideally, should be studied in an integrated way. The theoretical model presented in this article serves three main purposes: providing analytical clarity for organizing scientific data, encouraging further observation and causal testing, and identifying policy entry points.