A comparison of socioeconomic differences in physical functioning and perceived health among male and female employees in Britain, Finland and Japan
Introduction
In industrialized western European and north American countries health follows a hierarchical pattern: the lower the socioeconomic status, the poorer the health. European comparisons show that the magnitude of socioeconomic inequalities in ill-health and mortality vary among countries (Mackenbach, Kunst, Cavelaars, Groenhof, & Geurts, 1997a; Cavelaars et al., 1998; Kunst, Groenhof, Mackenbach, & Health, 1998; Lahelma et al., 2002). Furthermore, even when similar levels of inequalities in total mortality are observed, very different specific causes may be responsible; alcohol associated causes and cardiovascular diseases being important contributors to overall inequalities (Kunst et al., 1998).
These results highlight the importance of comparative studies in identifying the common and unique determinants of socioeconomic inequalities in health. Comparative studies help us to identify countries or settings with particularly large or small inequalities in health. Such studies can provide a possibility to try to identify the circumstances that are associated with inequalities in health. Small inequalities may, for example, be related to small inequalities in material conditions of life, favourable working conditions and equitable distribution of welfare services. These in turn limit the behavioural choices that individuals can make in terms of smoking, use of alcohol, exercise and intake of fruit and vegetables (Laaksonen, Prättälä, Helasoja, Uutela, & Lahelma, 2003). Comparing countries may sometimes be the only feasible way to evaluate how policy affects health inequalities, and thus help us to distinguish which among a multitude of factors has the greatest potential to reduce health differences. Simultaneously comparative studies improve our understanding of the limits and generalisability of explanations of inequalities in health obtained in particular national settings.
Relatively little comparative research on socioeconomic inequalities in health that include countries of non-European heritage are available. However, analyses of Japan indicate that socioeconomic inequalities in mortality, ill-health and risk factors exist, but the magnitude and pattern of these inequalities are not as consistent as in western countries (Kagamimori, Iibuchi, & Fox, 1983; Kagamimori et al., 1998; Netherlands Central Bureau of Statistics, 1992; Kawakami, Haratani, Hemmi, & Araki, 1992). For example, an earlier comparison of socioeconomic inequalities in risk factors among British and Japanese employed men showed, that although a ‘western inequality pattern’ was observed for some risk factors, it could not be observed for weight (BMI), waist-to-hip-ratio and HDL cholesterol (Martikainen, Ishizaki, Marmot, Nakagawa, & Kagamimori, 2001). Thus, caution is needed against uncritical extrapolation of results on health inequalities from western countries to non-western countries, such as Japan.
The aim of this study is to compare the patterns of socioeconomic inequalities in physical functioning and perceived health among male and female government employees in Britain, Finland and Japan. These three countries represent the ‘liberal’, the ‘Nordic’ or ‘social democratic’ and the ‘conservative’ welfare regimes, respectively, each characterised by a different pattern of welfare production and allocation (Mackenbach et al. (1990), Esping-Andersen (1999)). Previous evidence of health inequalities being associated with welfare regimes is inconclusive (Mackenbach et al., 1997a). ‘A welfare regime can be defined as the combined, interdependent way in which welfare is produced and allocated between state, market and family’ (Esping-Andersen, 1999, p. 35). Under this broad definition of a welfare regimes there are at least three factors that may be put forward as having a significant contribution for socioeconomic differences in health. These relate to the following: (1) differences in the direct material consequences of redistributive income policies and universalistic and egalitarian principles in the provision of social benefits, education and health care; (2) differences in the psychosocial and psychological consequences of these policies in terms of sense of belonging, feelings of cohesion and sense of security; and (3) differences in the working of the labour market in terms of gender segregation, the male ‘bread-winner’ model and the ability of women to participate in paid work.
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Participants
Participants of the Japanese, Finnish and British cohorts were recruited from municipal, provincial and national public sector work places. Because socioeconomic differences in ill-health in Japan are poorly documented, we use data for two different Japanese cohorts. Those invited to participate were sent a standardised self-report health questionnaire.
In Japan questionnaires were sent to the employees of a prefecture on the west coast of Japan (Kagamimori, Sekine, Nasermoaddeli, & Hamanisi,
Results
Proportionally more British employees work in the top grade than Japanese and Finnish employees (Table 1). In particular, very few Japanese women occupy higher grades. These differences are partly due to the higher socioeconomic composition of the British civil servants recruited from London based national government departments, and differences in the occupational structure between city and provincial employees. Among men and women differences in the prevalence of fair or poor perceived health
Socioeconomic differences among men
For men earlier studies comparing socioeconomic inequalities based on occupational social position in Britain and Finland suggest that the pattern and magnitude of health inequalities in these two countries is broadly similar for perceived health, but inequalities are perhaps somewhat larger in Finland for limiting long-standing illness (Lahelma, Arber, Rahkonen, & Silventoinen, 2000). However, differences in perceived health by household income were possibly a little larger in Britain (
Conclusion
Our results emphasize the importance of comparative studies of socioeconomic inequalities in health among men and women in different national settings. We have shown that socioeconomic differences in ill-health vary between Japanese, Finnish and British employees, and that particularly Japanese women show little evidence of the western pattern of inequality in health so far. Britain, Finland and Japan—representing ‘liberal’, ‘Nordic’ and ‘conservative’ welfare state regimes—produce broadly
Acknowledgements
This work is part of the European Science Foundation program on Social Variations in Health Expectancy in Europe, in particular the working group on Macrosocial Determinants of Morbidity and Mortality.
The Helsinki Health Study is supported by grants from the Academy of Finland, Research Council for Health (48119, 48553 and 53245) and the Finnish Work Environment Fund (99090).
The Whitehall II study has been supported by grants from the Medical Research Council, British Heart Foundation, Health
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