Up the downstream: Contributing mechanisms to the persistence of health inequalities in Norway
This dissertation aims to expand on the current empirical knowledge of and theoretical mechanisms in the social determinants of health. Specifically, it investigates the mechanisms by which social root causes generate health outcomes in order to assess within-state health inequalities in high-income countries such as Norway. It emphasizes the effect of material and immaterial resources that result from positioning in a social hierarchy, typically reflected by income, education, and occupational class.
Article I explores the income inequality--health hypothesis and its relation to income, psychosocial stress, and self-rated health. Using multilevel moderated mediation analysis, I show that while the income--health relationship is indeed mediated by psychosocial stress in all countries under study, this effect is not moderated by income inequality. I conclude that material effects of income at the individual level remain an important explanation of the income--health gradient.
Article II investigates the extent to which socioeconomic determinants of health (education, income, and occupational class) contribute to predicting non-communicable disease (NCD) prevalences. Further, it aims to non-parametrically assess how these health gradients look from the perspective of a random forest algorithm. We conclude that prediction is an important tool for scientific inquiry into health inequalities and potentially a useful tool for public health guidance, as it allows unpacking complex functional relationships between NCD outcomes and social determinants of health.
Article III shifts attention towards subnational trends in early life health care input. The article investigates to what extent local patterns of antibacterial dispensing rate trends in young children are associated with the proportion of the local population having achieved high levels of education. Results indicate that the ability to reduce dispensing rates over time at the municipal level is associated with mean population levels of higher education. Optimizing prescribing practices may require area-level strategies, and attention should be given toward sociodemographic challenges at the local level.
Overall, I show that material and immaterial social resources, and their value towards a market that reward said resources, remain important explanans of the persistence of health inequalities even in comparatively high-income and egalitarian countries such as Norway. I argue that the fundamental structures of social inequality must be considered when explaining the persistence of health inequalities, and that policies in pursuit of population health are limited in their ability to address this fundamental structure. Empirically, I show that material and immaterial advantage lead to better health outcomes both at the individual and population levels. Methodologically, I show that while methods of association are limited in their ability to estimate causal effects, important patterns of health inequalities can still be explored using novel statistical analyses on observational data.
Paper 1: Svalestuen, S. (2022). Is the mediating effect of psychosocial stress on the income–health relationship moderated by income inequality? SSM - Population Health, 20, 101302. Also available in Munin at https://hdl.handle.net/10037/27866.
Paper 2: Svalestuen, S., Sari, E., Langholz, P.L. & Vo, C.Q. (2023). The predictive importance of education, income, and occupation on non-communicable disease outcomes: results from the Tromsø Study. (Manuscript under review).
Paper 3: Svalestuen, S., Svendsen, K., Eggen, A.E. & Småbrekke, L. (2022). Association of area-level education with the regional growth trajectories of rates of antibacterial dispensing to patients under 3 years in Norway: a longitudinal retrospective study. BMJ Open, 12(9), e058491. Also available in Munin at https://hdl.handle.net/10037/27492.
PublisherUiT Norges arktiske universitet
UiT The Arctic University of Norway
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