Swiss Health Space
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Swiss Health Space An explorative analysis of health perception and its relationship to socio-demographic and geographic characteristics Dissertation zur Erlangung der naturwissensehaftliehen Doktorwürde (Dr. se. nat.) vorgelegt der Mathematiseh-naturwissensehaftliehenFakultãt der Universitãt Zürieh von Charis Lengen von Embd (VS) Promotionskomitee . Prof. Dr. Sara Fabrikant (Vorsitz, Leitung der Dissertation) Prof. Dr. Ulrike Müller-Bõker Prof. Dr. Kurt Brassel Zürieh 2006 Summary The purpose of this research is to uncover potential relationships that might exist between people's self-reported health, their socio-demographic backgrounds, and the place where they live in Switzerland. Numerous studies have suggested relationships between health and education, socio-economic position and income inequality. There is also increasing evidence that certain locational characteristics (e.g., residential area and neighbourhood) and people's individual characteristics may be independently related to a person's health. Epidemiological approaches and the use of Geographical Information Systems (GIS) have become popular methods in medical geography. However, explorative (spatial) data analysis to investigate the multidimensional complexity of health has not been fully exploited yet. Applying multivariate exploratory data analysis methods, this thesis aims to reveal latent relationships within health characteristics extracted from the Swiss Health Survey (SHS). In contrast to the deductive, indicator-based health analysis methods commonly used in medical geography, this research employs an empirical and inductive perspective to health, based on health and well-being relationships extracted from individual health surveys. The following research questions are addressed: What kinds ofhealth assessment are available to analyse individual health, in particular health perception in Switzerland? What kind of conceptual health model can be constructed to explore individual health and health perception? What kind oflatent structures can be uncovered in Swiss health surveys? Do relationships exist between self-reported health characteristics? Do relationships exist between self-reported health, socio-demographic backgrounds, cultural differentiation, and geographicallocations? A three-step health data analysis process is proposed to answer the posed research questions: (1) the feasibility of dimensionality reduction methods is investigated to project multivariate hea1th datasets into a conceptual health space model, (2) analytical and statistical methods are employed to systematically explore the pattems found in the constructed health space concept, and (3) uncovered latent structures and relationships are interpreted based on solid theoretical foundations. A Swiss health space model has been constructed based on a set of 16 health characteristics extracted from the Swiss Health Survey, including self-reported general health, mental health characteristics, and recent symptoms. Categorical principal component analysis (CatPCA) was employed to systematically explore potential re1ationships between people's health perception and their socio-demographic backgrounds such as, age, household income, gender, and educationallevel. Additionally, language area types, municipality types and region types were inc1uded in the analysis as supplementary variables. Although health measures are often treated as quantitative (e.g., typically ordinal or metric), they were kept at a nominallevel of measurement, in order to be able to uncover potential non-linear relationships within the constructed health space. The Swiss Health Survey is the largest avai1able health assessment dataset for Switzer1and. I discovered two major latent structures in the constructed health space (e.g., health dimensions) in the se1ected multivariate database. The first dimension represents a continuum of general health and mirrors the distinction between those reporting to have good general health and those reporting having poor general health. The second dimension distinguishes mental and physical health characteristics. This may be interpreted within the scope of the body/mind dualism concept. The constructed health space mode1 externalizes the health perception of survey respondents in Switzerland. The health space is a kind of collective internal health perception. In this two-dimensional space, 'c1usters' of mental health and physical health can be detected. Other health characteristics such as health-related well-being and medication show a strong positive association with physical health in the space. Socio demographic variables and spatial differentiation in Switzerland seem not to have strong explanatory powers. Knowledge about latent relationships within self-reported health characteristics is relevant for research in medical geography, as well as for epidemiology and public health. Perceived health influences risk behaviour being a part of disease ecology, as well as health care uti1isation. This thesis provides a methodological foundation on how medical geographers could employ exploratory data analysis methods to systematically uncover latent relationships buried in other large self-reported health databases. The developed health space concept provides ample opportunity for further health investigations. For example, record linkages of SHS or similar databases with general health indicators such as mortality rates or diagnosis-based indicators (e.g., based on the international c1assification of diseases (ICDI0», could be envisioned to reach a deeper understanding of health. Health space of different cultural backgrounds and geographicallocations could be constructed and systematically compared. This could not only provide health researchers with new insights into how people's well-being might relate to their individual characteristics, but also be of ii interest to medical geographers who might be interested in how individual differences in health perception might be related to societal and geographical differentiation. iii Zusammenfassung Seit einigen Jahren wird in zahlreichen Studien der Zusammenhang zwischen Gesundheit, Erziehung, sozioõkonomischer Position und Einkommen untersucht und die soziale Ungleichheit für eine schlechtere Gesundheit verantwortlich gemacht (Mielck, 1998; Sturm und Gresenz, 2002; Subramanian und Kawachi, 2004; Sundquist und Johansson, 1998). Einige Forscher weisen jedoch darauf hin, dass neben diesen soziodemographischen Faktoren auch vom 1ndividuum nicht direkt beeinflussbare kollektive Faktoren und Rahmenbedingungen eine Rolle fUr Gesundheit und Wohlbefinden spielen (Hart et al., 1997; Macintyre et al., 1993; Mitchell et al., 2000). Für geographische Ansãtze sind gebietsgebundene Faktoren wie Charakteristika des Wohnortes und des sozialen Umfelds in der Nachbarschaft, das Vertrauen und die 1nteraktion mit der Gemeinschaft sowie die regionale 1dentitãt besonders Erfolg versprechend (Lochner et al., 1999; Malmstrõm et al., 2001; Mitchell et al., 2000; Subramanian et al. 2001). Ecob und Macintyre (2000) weisen jedoch daraufhin, dass der Einfluss von gebietsgebundenen Faktoren auf das gesundheitliche Verhalten von der Art und Weise abhãngt, wie die Gebiete und die Gesundheit gemessen werden. 1m Gegensatz zu den erwãhnten Studien folgen Gatrell et al. (2004) dem Ansatz des franzõsischen Soziologen Bourdieu, indem sie soziale Ungleichheiten in, einem zweidimensionalen sozialen Raum visualisieren und die Wohnorte sowie Morbiditãtsdaten in diesen sozialen Raum projizieren. Auf diese Weise untersuchen sie in einer multiplen Korrespondenzanalyse die Relationen zwischen sozialen Faktoren, Wohnort und Gesundheit. Das Ziel dieser Arbeit war unter Berücksichtigung soziodemographischer Aspekte und der geographischer Differenzierung die gesundheitliche Wahrnehmung der Schweizer Bevõlkerung zu untersuchen. Dazu sollte geeignetes Datenmaterial gesucht und die entsprechende statistische Methodik gewãhlt werden. Dabei sollte der Komplexitãt und Relationalitãt der gesundheitlichen Wahrnehmung besondere Aufmerksamkeit geschenkt werden. Folgende Forschungsfragen wurden gestellt: 1. Welche Gesundheitsmessungen und gesundheitlichen Charakteristika sind verfügbar, um die Gesundheit, insbesondere die gesundheitliche Wahrnehmung der Schweizer Bevõlkerung zu messen? 2. Wie kõnnen wir mit explorativen Datenanalysen die gesundheitliche Wahrnehmung analysieren und einen konzeptionellen Gesundheitsraum konstruieren? 3. Existieren verborgene Strukturen und Beziehungen in den Gesundheitsdaten, insbesondere den Selbstangaben zur Gesundheit und wennja, welcher Art sind sie. iv 4. Kann die gesundheitlichen Wahrnehmung der befragten Schweizer Bevolkerung durch sozio-kulturelle Unterschiede und raumliche Variation erklart werden? Die Schweizerische Gesundheitsbefragung erschien nach gründlicher Abklarung der "Gesundheitsdatenlandschaft' (Keller-Lengen und Bopp, 2004) die geeignete Datenbasis fur unsere Untersuchung zur gesundheitlichen Wahrnehmung der Schweizer Bevolkerung zu sein. Die Korrespondenzanalyse (CA) und die kategorielle Hauptkomponentenanalyse (CatPCA) boten sich als geeignete explorative Datenanalyse an, um die multivariaten kategoriellen und kontinuierlichen Daten der Schweizerischen Gesundheitsbefragung zu analysieren. In Psychologie und Soziologie sind CA und CatPCA etabli erte multivariate Datenanalysemethoden, in der Geographie werden diese Methoden noch nicht so haufig eingesetzt. Wie bei induktiven Ansatzen üblich, werden mit CA und CatPCA Relationen zwischen