Is universal healthcare truly universal? Socioeconomic and migrant inequalities in healthcare

Doctoral thesis (2022)

Through the principle of Universal Healthcare Coverage, many governments across Europe and beyond seek to ensure that all people have equal access to good quality healthcare services, without facing a ... [more ▼]

Through the principle of Universal Healthcare Coverage, many governments across Europe and beyond seek to ensure that all people have equal access to good quality healthcare services, without facing a financial burden. Despite this, studies have highlighted persistent migrant and socio-economic inequalities in the use of healthcare services, and personal health records. Therefore, understanding the complex mechanisms that produce and maintain social inequalities in the effective use of healthcare services is thus an important step towards advancing equity in healthcare. This thesis draws on Bourdieu's forms of capital (cultural, social, economic, and symbolic) to conceptualise and empirically test social inequalities related to healthcare. In doing so, it investigates the factors contributing to socioeconomic and migrant inequalities in the use, navigation and optimisation of healthcare services as well as personal health records. The three studies that make up this thesis empirically test these ideas through statistical modelling on population-based datasets as well as through the analysis of two cross-sectional surveys in Luxembourg and the Greater region. The first study draws on the fifth wave of the Survey of Health, Aging, and Retirement in Europe (SHARE). It used cluster analysis and regression models to explain how the unequal distribution of material and non-material capitals acquired in childhood shape health practices, leading to different levels of healthcare utilisation in later life. The results suggest that although related, both material and non-material capitals independently contribute to health practices associated with the use of healthcare services. The second study used data from a cross-sectional survey to investigate inequalities in the navigation and optimisation of healthcare services, taking into consideration the interplay between perceived racial discrimination and socioeconomic position. It revealed disparities between individuals born in Eastern Europe and the Global South and those born in Luxembourg which were explained by the experience of racial discrimination. It also found that the impact of discrimination on both health service navigation and optimisation was reduced after accounting for social capital. The last study used data from a cross-sectional survey developed as a part of a collaborative project (INTERREG-APPS) to examine the socioeconomic and behavioural determinants in the intention to use personal health record in the Greater region of Luxembourg (Baumann et al., 2020). This study found that people’s desire and actual access to personal health electronic records is determined by different socioeconomic factors, while educational inequalities in the intention to regularly use personal health records were explained by the role of behavioural factors. Taking together, the findings presented in this thesis thus show the value of mobilising Bourdieu’s theoretical framework to understand the mechanisms through which social inequalities in healthcare develop. In addition, it showed the importance of considering racial discrimination when examining migrant, and racial/ethnic differences in health. [less ▲]

The positional value of education in the Americas: dynamics of inequality in labour market returns for highly unequal countries, 2000-2019

Scientific Conference (2022, April 22)

The article examines how the labour market value of education has changed in the context of the expansion of higher education. However, one drawback is understanding how it generates differences between ... [more ▼]

The article examines how the labour market value of education has changed in the context of the expansion of higher education. However, one drawback is understanding how it generates differences between high and low-skilled labour markets, particularly in contexts of high inequality and informality. This could be linked to specific mechanisms by which employers value educational credentials as signalled skills. Using the Luxembourg Income Study (LIS), we analyse trends over two decades in 11 American countries. Our results confirm the previous results for the claim that education has become increasingly positional, compared with the absolute model of education. However, we find that the relative gains in wages for workers with higher levels of education, as the pool of higher education graduates expand over time, increased only slightly in high-skilled occupations, while their relative gains decreased for lower-skilled occupations. This trend is present in both absolute and positional models of education. Moreover, when looking at the structure of labour markets in terms of the linkage between educational credentials and occupational groups, we higher the tertiary education specificity of occupations, the higher the earnings for workers with advantaged positions. These findings are consistent with processes of displacement of low-skilled workers due to increasing competition among highly educated workers, from the positional model of education. [less ▲]

The positional value of education in the Americas: dynamics of inequality in labour market returns for highly unequal countries, 2000-2019

Scientific Conference (2021, November 17)

The article examines how the labour market value of education has changed in the context of the expansion of higher education. However, one drawback is understanding how it generates differences between ... [more ▼]

The article examines how the labour market value of education has changed in the context of the expansion of higher education. However, one drawback is understanding how it generates differences between high and low-skilled labour markets, particularly in contexts of high inequality and informality. This could be linked to specific mechanisms by which employers value educational credentials as signalled skills. Using the Luxembourg Income Study (LIS), we analyse trends over two decades in 11 American countries. Our results confirm the previous results for the claim that education has become increasingly positional, compared with the absolute model of education. However, we find that the relative gains in wages for workers with higher levels of education, as the pool of higher education graduates expand over time, increased only slightly in high-skilled occupations, while their relative gains decreased for lower-skilled occupations. This trend is present in both absolute and positional models of education. Moreover, when looking at the structure of labour markets in terms of the linkage between educational credentials and occupational groups, we higher the tertiary education specificity of occupations, the higher the earnings for workers with advantaged positions. These findings are consistent with processes of displacement of low-skilled workers due to increasing competition among highly educated workers, from the positional model of education. [less ▲]

The very long arm of wealth: Effects of intergenerational wealth resources on health in the U.S. over the last three decades

E-print/Working paper (2021)

Health inequalities result from multidimensional socioeconomic inequalities (income, education, wealth, etc.). Given the specific size and greater stability through time of wealth than income, wealth ... [more ▼]

Health inequalities result from multidimensional socioeconomic inequalities (income, education, wealth, etc.). Given the specific size and greater stability through time of wealth than income, wealth might affect health beyond other socioeconomic indicators. An important question is how far the reach of wealth is on one’s health: Does wealth promote health even over generations? Using the Panel Study of Income Dynamics (PSID), we consider the effects of intergenerational and intragenerational wealth on age-adjusted self-assessed health (ASAH) across the life course. We find that both parental and personal household wealth strongly affect ASAH net of other socioeconomic measures. Just as social disadvantages have been shown to be inherited between generations, so too are wealth-induced health advantages. Furthermore, the inter- and intra- generational wealth effects on health increase over the life course. This study thus encourages social scientists to pay greater attention to wealth inequalities, despite difficulties in their accurate measurement. [less ▲]

Processus de civilisation, inégalités extrêmes et violence de masse

in Scheidel, Walter (Ed.) UNE HISTOIRE DES INÉGALITÉS : DE L’ÂGE DE PIERRE AU XXIe SIÈCLE (2021)

Detecting the ‘Black Hole’ of age-period excess mortality in 25 countries: Age-period-cohort residual analysis

in Bell, Andrew (Ed.) Age, Period, and Cohort Effects (2021)

In a time of worldwide availability of annual age-specific mortality data, we lack basic tools for detecting and graphing, from a comparative perspective, fine-grained deviations from mortality trends. We ... [more ▼]

In a time of worldwide availability of annual age-specific mortality data, we lack basic tools for detecting and graphing, from a comparative perspective, fine-grained deviations from mortality trends. We provide a new age-period-cohort-based methodology, combining information from age-period (AP) and APC-Detrended (APCD) analyses to detect all-cause mortality increases. Plotting the resulting AP coefficients and APCD residuals in equilateral Lexis diagrams, mortality patterns can easily be distinguished as age, period, or cohort trends and fluctuations. We highlight abnormalities as interactions of age and period (‘Black Holes’). We then investigate the ‘Black Holes’ of mortality of young-adult cohorts in the early 1990s in Spain, other southern European countries, and the U.S., in emphasizing their simultaneously occurring mortality crises. Additional analyses with WHO mortality data and epidemiological evidence from other studies show that these mortality increases likely result from lack of treatment and inadequate public health responses to the beginnings of the HIV/AIDS epidemic. We discuss other possible applications of the new method. [less ▲]

Cross-border mobility in European countries: associations between cross-border worker status and health outcomes

in BMC Public Health (2021), 21

Mobility of workers living in one country and working in a different country has increased in the European Union. Exposed to commuting factors, cross-border workers (CBWs) constitute a potential high-risk ... [more ▼]

Mobility of workers living in one country and working in a different country has increased in the European Union. Exposed to commuting factors, cross-border workers (CBWs) constitute a potential high-risk population. But the relationships between health and commuting abroad are under-documented. Our aims were to: (1) measure the prevalence of the perceived health status and the physical health outcomes (activity limitation, chronic diseases, disability and no leisure activities), (2) analyse their associations with commuting status as well as (3) with income and health index among CBWs. Based on the ‘Enquête Emploi’, the French cross-sectional survey segment of the European Labour Force Survey (EU LFS), the population was composed of 2,546,802 workers. Inclusion criteria for the samples were aged between 20 and 60 years and living in the French cross-border departments of Germany, Belgium, Switzerland and Luxembourg. The Health Index is an additional measure obtained with five health variables. A logistic model was used to estimate the odds ratios of each group of CBWs, taking non-cross border workers (NCBWs) as the reference group, controlling by demographic background and labour status variables. A sample of 22,828 observations (2456 CBWs vs. 20,372 NCBWs) was retained. The CBW status is negatively associated with chronic diseases and disability. A marginal improvement of the health index is correlated with a wage premium for both NCBWs and CBWs. Commuters to Luxembourg have the best health outcomes, whereas commuters to Germany the worst. CBWs are healthier and have more income. Interpretations suggest (1) a healthy cross-border phenomenon steming from a social selection and a positive association between income and the health index is confirmed; (2) the existence of major health disparities among CBWs; and (3) the rejection of the spillover phenomenon assumption for CBWs. The newly founded European Labour Authority (ELA) should take into account health policies as a promising way to support the cross-border mobility within the European Union. [less ▲]

Logically Centralized Security for Software-Defined Networking

Doctoral thesis (2020)

Software-Defined Networking (SDN) decouples the control and data planes of traditional networks, logically centralizing the functional properties of the network in the SDN controller. While this ... [more ▼]

Software-Defined Networking (SDN) decouples the control and data planes of traditional networks, logically centralizing the functional properties of the network in the SDN controller. While this centralization brought advantages such as a faster pace of innovation, it also disrupted some of the natural defenses of traditional architectures against different threats. Until now, SDN research has essentially been concerned with the functional side, despite some specific works relating to non-functional properties like ‘security’, ‘dependability’, or ‘quality of service’. Security is an essential non-functional property of SDN. The lack of reliable security-by-design mechanisms can quickly lead to the compromise of the entire network. For instance, most of the current security mechanisms in SDN controllers lead to exploitable vulnerabilities that allow adversaries to easily control or even shut down the entire control plane. The growing concern regarding insider threats substantially amplifies the problem. The reason lies in the fact that current Software-Defined Networks (SDNs) (e.g., OpenFlow-enabled networks) rely on weak protection mechanisms. To address these crucial security issues in the SDN control plane, it is necessary, though not sufficient, that we start by securely identifying, authenticating, and authorizing all devices before allowing them to become part of the network. Though SDN security is the central tenet of this thesis, we believe that the problem is much more generic. In essence, there is still a lack of a systematic approach to ensuring such relevant non-functional properties as security, dependability, or quality of service. Current approaches are mostly ad-hoc and piecemeal, which has led to efficiency and effectiveness problems. This reflection led us to claim that the successful enforcement of non-functional properties as a pillar of SDN robustness calls for a systematic approach. We further advocate, for its materialization, the re-iteration of the successful formula behind SDN– ‘logical centralization’. In consequence, we propose ANCHOR, a subsystem architecture for SDN that promotes the logical centralization of non-functional properties. We start by presenting the general concept and architectural principles, suggesting how they can satisfactorily enhance the current state of the art with regard to any non-functional property (security, dependability, performance, quality of service, etc.). We claim and justify that centralizing such mechanisms is vital for their effectiveness, by allowing us to: define and enforce global policies for those properties; reduce the complexity of controllers and forwarding devices; ensure higher levels of robustness for critical services; foster interoperability of the non-functional property enforcement mechanisms; and finally, better foster the resilience of the architecture itself. We focus on ‘security’ as a use case in the rest of the thesis, discussing the specialization of the ANCHOR architecture to logically-centralized enforcement of security properties. However, by presenting a principled solution to the main problem of the thesis (SDN security), we also show the effectiveness of the general ANCHOR concept, opening avenues for further research on its extension to other desirable non-functional properties, such as dependability and Quality of Service (QoS). We identify the current security gaps in SDNs, and investigate the adequate security mechanisms that should populate the architecture middleware, globally and consistently. ANCHOR sets out to provide — in a homogeneous manner to all controllers and forwarding devices — essential security mechanisms such as strong entropy, resilient pseudo-random generators, secure device registration, association and recommendation, amongst other crucial services. We present the design of those mechanisms and protocols. With the objective of promoting generalized use of encryption and authentication in the control plane, we additionally propose and describe a secure control plane communication infrastructure, Keep It Simple and Secure (KISS), based on a novel lightweight mechanism for generating cryptographic secrets — integrated Device Verification Value (iDVV). iDVV can be used in a number of ways, in a number of protocols, and outperforms widely used alternatives. In the context of this thesis, the KISS infrastructure is set up by ANCHOR and used to ensure the security of interactions amongst it, controllers and forwarding devices. Being conceptually logically-centralized, ANCHOR presents a single-point-of-failure (SPoF) challenge, which we address, through incremental measures, some of which can be selectively present in concrete designs. As a baseline, we harden the design, by endowing it with robust functions in the different modules. We increase assurance by discussing and informally proving correctness of all mechanisms and algorithms, and we also formally verify the main algorithms through a proof-assistant. By only using symmetric cryptography, we make the system Post-Quantum Secure (PQS). We also embed measures to achieve Perfect Forward Secrecy (PFS) in all algorithms, protecting pre-compromise communications in the presence of successful attacks. Finally, for higher criticality systems, we take additional algorithmic and architectural measures to mitigate the effects of possible security failures. We provide for Post-Compromise Security (PCS) through the semi-automatic restart of operation after a full compromise of ANCHOR. We present as well a design of resilience mechanisms — the continued prevention of failure/compromise by automatic means — through fail-fast recovery techniques. The prototypes’ implementation aspects and the evaluation of the two fundamental pieces of our work (ANCHOR and KISS) are performed in the respective chapters. The above-mentioned discussion and informal proof of correctness of all mechanisms and algorithms is given in appendices. We also formally machine- verified the main algorithms. [less ▲]

The patients’ perspective on access to and use of Personal Health Records

Scientific Conference (2020)

We present the patients' perspective regarding the use of Personal Health Records, and give insights on patients' characteristics, such as socioeconomic and behavioural factors, that are associated with ... [more ▼]

We present the patients' perspective regarding the use of Personal Health Records, and give insights on patients' characteristics, such as socioeconomic and behavioural factors, that are associated with the access to and use of Personal Health Records. The findings come from the INTERREG APPS project that investigated preferences for and intention to use Personal Health Records in four cross-border regions, in Lorraine/France, Luxembourg, Rhineland-Palatinate and Saarland/Germany, and Wallonia/Belgium. [less ▲]

Losing ground in the income hierarchy: relative deprivation revisited

in Journal of Economic Inequality (2020), 18

The paper discusses a one-parameter generalization of individual relative deprivation measures to a two-period setting that differs from earlier approaches. The parameter is, by definition, independent of ... [more ▼]

The paper discusses a one-parameter generalization of individual relative deprivation measures to a two-period setting that differs from earlier approaches. The parameter is, by definition, independent of the income distributions under consideration—it is to be chosen by a social planner. Its value has an intuitive interpretation: it represents the additional weight assigned to the income shortfalls associated with agents who passed the individual in question when moving from yesterday’s income distribution to today’s. Therefore, the choice of this parameter represents an important value judgment on the part of a social planner regarding the relative impact of being left behind. As a special case, it is illustrated how the well-known Yitzhaki index can be extended to this environment. [less ▲]