Social policies and the pathways to inequalities in health: a comparative analysis of lone mothers in Britain and Sweden
Introduction
From both a social policy and a health perspective, lone parent families are now being acknowledged as one of the most disadvantaged groups in society in many countries. They are frequently at higher risk of poverty, of unemployment and are one of the groups about whom there is concern over social exclusion (Bradshaw et al., 1993, Duncan and Edwards, 1997a, Hobson, 1994, Kanata and Banks, 1997, Lewis, 1997a, Roll, 1989, Schlesinger and Schlesinger, 1994, Sorensen, 1994, Wong et al., 1993). The overwhelming majority of lone parents in all countries are women.
From a health perspective, there is a body of evidence from Britain, Sweden and other OECD countries indicating a health disadvantage for lone mothers and their children compared with their counterparts in two parent families (Benzeval, 1998, Blaxter, 1990, Burström et al., 1999, Elstad, 1996, Forssén and Janlert, 1991, Graham and Blackburn, 1998, Kotler and Wingard, 1989, Martikainen, 1995, Popay and Jones, 1990, Shouls et al., 1999, Walters, 1993, Wasserman, 1990). As the concept of the social model of health gains ground, there is growing recognition that health is influenced by a range of individual, social, community and macro-economic/cultural factors which are in part the consequence of public policy decisions (Whitehead, 1995). This has resulted in calls for health impact assessment of policies outside the health sector that may impinge on lone parents. For example, in 1997, the Council of Europe issued recommendation No.R (97) 4 on securing and promoting the health of single-parent families, which called on European governments to set up “assessment of the health impact of different policies from the single-parent perspective“ (Council of Europe, 1997).
Yet to date there have been few attempts to join the two perspectives of policy analysis and health research to make such a health impact assessment, partly because of the complexity of the task. Going one step further, the recent Independent Inquiry into Inequalities in Health (1998) in its first recommendation called for health inequalities impact assessment of policies. This would require a deeper understanding of how policies help to generate and maintain social inequalities in society and in turn lead to poorer health.
The aim of the study reported here is to contribute to the emerging field of health and health inequalities impact assessment. First, it aims to develop further a conceptual framework which encompasses the policy context, as well as the pathways leading from social position to inequalities in health; and second, to use the framework to make an assessment focussed on a specific population group of health and policy concern — lone mothers. The study takes advantage of the very different policy contexts in Britain and Sweden over the past 20 years in relation to lone mothers. As a consequence, not only may the health outcome for lone mothers differ, but the pathways to that health outcome may vary, and may shed light on possible points of policy intervention for the future.
The paper is divided into three sections. The first presents the conceptual framework we have adopted to consider national policies and their points of potential impact on the health of lone compared to couple mothers. The second section uses the framework to examine relevant policies over the past two decades in Sweden and Britain, and presents empirical analyses at some of the points along the pathways leading from lone motherhood to ill health. In the third section, we discuss the implications of the findings for future policy and research.
Section snippets
Conceptual framework
For this study we adopted a simplified version of Diderichsen’s conceptual framework of policy impact on social pathways to inequalities in health (Diderichsen and Hallqvist, 1999), depicted in Fig. 1. In this framework, the pathways leading to ill health can be approached from the perspective of the individual or of society. One line of enquiry considers an individual’s social position (defined by their gender, occupational class or ethnic origin, for example) and how that position influences
Data and methods
Through policy and literature review and empirical analysis of household survey data, we explored the pathways leading to the health disadvantage of lone mothers at various points of potential policy impact outlined in Fig. 1. For the policy analysis, official policy documents and routinely collected population health and scocioeconomic statistics were reviewed, and literature searches (both electronic and manual) were carried out on cross-country comparative social policy studies related to
The link between lone motherhood and health
The basic question, which needs to be answered before investigating the pathways further, is whether there is an association between lone motherhood and health with the indicators used. Table 1 shows that lone mothers had significantly poorer health than couple mothers for both health indicators in both countries and all 4 time periods. The odds ratios indicate that the health gap between lone and couple mothers remained fairly constant over the study period, with lone mothers having between 61
Discussion
This study provides new insights into the mechanisms underlying the health disadvantage of lone mothers in the two countries, but it also raises several fundamental questions which need to be unravelled further.
A basic methodological issue inherent in our cross-sectional study design is whether negative health-related selection into lone motherhood contributes to our findings. According to this hypothesis, lone mothers may be lone mothers because they are unhealthy, and because they are
Acknowledgements
We would like to thank Susanna Shouls for extracting the original GHS data files and preparing the variables for comparative purposes. This research was jointly funded, on the British side by the ESRC under the Health Variations Programme, grant number L1282251029, and on the Swedish side by grants from the National Institute of Public Health and Stockholm County Council. Data from the British General Household Survey were made available through the Office for National Statistics and the ESRC
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