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Health inequalities in Switzerland

Health inequalities in Switzerland: The role of intersectional and contextual determinants

Summary

The Swiss Federal Office of Public Health highlighted persisting health inequalities in Switzerland (Weber 2020). It stressed that social disadvantages shaped by factors such as socioeconomic status, migration status and gender affected health outcomes. Namely, social environment influences individuals’ access to material, social and cultural resources, and subsequently their health. The present project aims to investigate the multiple determinants of health both at the individual and contextual level, and how these produce health inequalities.

A considerable amount of research has aimed at isolating the effect of (risk) factors (e.g. socioeconomic status, age, nationality, and employment status) on health, or focused on single determinants of health. Nevertheless, multiple factors may interact with one another, thereby amplifying or reducing their effects on health and health behaviours. Such interactions between individual resources resonate with the intersectionality theory. This framework has highlighted that individuals’ social positions are defined by numerous factors, such as gender, age, socioeconomic status, sexual orientation, ethnicity, etc (Bowleg, 2012; McCall, 2005). These social positions determine access to resources, status, power and capital, and entail a unique set of accumulated (dis)advantages. The health of individuals and population (sub)groups are shaped at the intersection of these multiple factors, which also relate to structural and interpersonal power relations, such as gender inequality and racism (Bowleg, 2012; Collins, 1992). Intersectionality research has first developed with qualitative studies (Bauer, 2014; Bowleg, 2008), and more recently emerged in quantitative and population health research (Bauer et al., 2021). Innovative statistical designs, such as “intersectional multilevel methods”, have allowed to model multiple intersectional strata and overcome the limitations of past fixed-effect approaches (Evans, 2019; Evans et al., 2018; Merlo, 2018). These advances open promising paths to study health inequalities from an intersectional perspective and with quantitative data. Hence, drawing on nationally representative survey data, such as the Swiss Health Interview Survey (SHIS) or the Swiss Labour Force Survey (SLFS), this project aims to examine how multiple determinants intersect and shape health across different population subgroups (e.g. low income single-mother, migrant with high education level, older individuals living alone, etc.).

Social epidemiology and public health research have produced a vast number of studies focused on individual-level determinants of health. However, recent studies have increasingly paid attention to macrolevel factors and emphasised the importance of contextualising social determinants of health (Beckfield 2015; Jolidon 2021; Sieber 2022). While socioeconomic gradients in health are widely reported, fewer studies have examined how macrolevel institutions (e.g. social policies, healthcare systems, macrosocial structures etc.) shape these gradients. That is, macrolevel and contextual factors may modify the effect of individual-level determinants, and these should thus be contextualised. Consequently, the present project aims to study the role of contextual factors on population health and health inequalities. It puts forward the use of models which can simultaneously consider (and isolate the effects of) both micro and macrolevel factors, such as multilevel regression or fixed-effect models.

Project objectives

• Investigating the intersectional and contextual determinants of health inequalities.
• Promoting the study of health inequalities in the context of Switzerland, with a focus on disadvantaged population subgroups and the effect of policies on health.
• Applying innovative statistical models to examine how contextual and intersectional determinants affect health, health behaviours and healthcare participation in the population.
• Encouraging undergraduate and graduate students to research health inequalities and their relations to social and contextual determinants, particularly in Switzerland.
  

Project leaders

• Prof Claudine Burton-Jeangros, Institute of Sociological Research, AV����Ƶ
• Dr Stéphane Cullati, Population Health Laboratory, AV����Ƶ of Fribourg; Institute of Sociological Research, AV����Ƶ
• Dr Vladimir Jolidon, Population Health Laboratory, AV����Ƶ of Fribourg; Institute of Sociological Research, AV����Ƶ

Project participants

• Dr Stefan Sieber, LIVES Centre, Swiss Centre of Expertise in Life Course Research, AV����Ƶ of Lausanne

Timeline

• January 2023 – January 2027

References

Bauer, G.R., 2014. Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Social Science & Medicine, 110, pp.10–17.

Beckfield, J., Bambra, C., Eikemo, T.A., Huijts, T., McNamara, C., Wendt, C., 2015. An institutional theory of welfare state effects on the distribution of population health. Social Theory & Health, 13, pp.227–244.

Bowleg, L., 2012. The problem with the phrase women and minorities: Intersectionality—An important theoretical framework for public health. American Journal of Public Health, 102, pp.1267–1273.

Collins, P.H., 1992. Black feminist thought: Knowledge, consciousness, and the politics of empowerment—Reply. Gender & Society, 6, pp.517–519.

Evans, C.R., 2019. Adding interactions to models of intersectional health inequalities: Comparing multilevel and conventional methods. Social Science & Medicine, 221, pp.95–105.

Evans, C.R., Williams, D.R., Onnela, J.P., Subramanian, S.V., 2018. A multilevel approach to modeling health inequalities at the intersection of multiple social identities. Social Science & Medicine, 203, pp.64–73.

Jolidon, V., Bracke, P., Burton-Jeangros, C., 2021. Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries. SSM - Population Health, 15, 100830.

McCall, L., 2005. The complexity of intersectionality. Signs, 30, pp.1771–1800.

Merlo, J., 2018. Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) within an intersectional framework. Social Science & Medicine, 203, pp.74–80.

Sieber, S., Orsholits, D., Cheval, B., Ihle, A., Kelly-Irving, M., Delpierre, C., Burton-Jeangros, C., Cullati, S., 2022. Social protection expenditure on health in later life in 20 European countries: Spending more to reduce health inequalities. Social Science & Medicine, 292, 114569.

Weber, D., 2020. Égalité des chances dans la promotion de la santé et la prévention en Suisse: Définitions, introduction théorique, recommandations pratiques. Rapport de base. Berne: PSCH, OFSP, CDS.

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