Austerity and old-age mortality in England: a longitudinal cross-local area analysis, 2007-2013

Objective

There has been significant concern that austerity measures have negatively impacted health in the UK. We examined whether budgetary reductions in Pension Credit and social care have been associated with recent rises in mortality rates among pensioners aged 85 years and over.

Design

Cross-local authority longitudinal study.

Setting

Three hundred and twenty-four lower tier local authorities in England.

Main outcome measure

Annual percentage changes in mortality rates among pensioners aged 85 years or over.

Results

Between 2007 and 2013, each 1% decline in Pension Credit spending (support for low income pensioners) per beneficiary was associated with an increase in 0.68% in old-age mortality (95% CI: 0.41 to 0.95). Each reduction in the number of beneficiaries per 1000 pensioners was associated with an increase in 0.20% (95% CI: 0.15 to 0.24). Each 1% decline in social care spending was associated with a significant rise in old-age mortality (0.08%, 95% CI: 0.0006–0.12) but not after adjusting for Pension Credit spending. Similar patterns were seen in both men and women. Weaker associations observed for those aged 75 to 84 years, and none among those 65 to 74 years. Categories of service expenditure not expected to affect old-age mortality, such as transportation, showed no association.

Conclusions

Rising mortality rates among pensioners aged 85 years and over were linked to reductions in spending on income support for poor pensioners and social care. Findings suggest austerity measures in England have affected vulnerable old-age adults.

The impact of the housing crisis on self-reported health in Europe: multilevel longitudinal modelling of 27 EU countries

Background: Many EU nations experienced a significant housing crisis during the Great Recession of 2008–10. We evaluated the consequences of housing payment problems for people’s self-reported overall health. Methods: We used longitudinal data from the EU Statistics on Income and Living Conditions survey covering 27 countries from 2008 to 2010 to follow a baseline sample of persons who did not have housing debt and who were employed (45 457 persons, 136 371 person–years). Multivariate linear regression and multilevel models were used to evaluate the impact of transitions into housing arrears on self-reported health, correcting for the presence of chronic illness, health limitations, and other potential socio-demographic confounders. Results: Persons who transitioned into housing arrears experienced a significant deterioration in self-reported overall health by − 0.03 U (95% CI − 0.01 to − 0.04), even after correcting for chronic illness, disposable income and employment status, and individual fixed effects. This association was independent and similar in magnitude to that for job loss (−0.02, 95% CI: −0.01 to − 0.04). We also found that the impact of housing arrears was significantly worse among renters, corresponding to a mean 0.11 unit additional drop in health as compared with owner-occupiers. These adverse associations were only evident in persons below the 75th percentile of disposable income. Discussion: Our analysis demonstrates that persons who suffer housing arrears experience increased risk of worsening self-reported health, especially among those who rent. Future research is needed to understand the role of alternative housing support systems and available strategies for preventing the health consequences of housing insecurity.

Fit-for-work or fit-for-unemployment? Does the reassessment of disability benefit claimants using a tougher work capability assessment help people into work?

BACKGROUND

Many governments have introduced tougher eligibility assessments for out-of-work disability benefits, to reduce rising benefit caseloads. The UK government initiated a programme in 2010 to reassess all existing disability benefit claimants using a new functional checklist. We investigated whether this policy led to more people out-of-work with long-standing health problems entering employment.

METHOD

We use longitudinal data from the Labour Force Survey linked to data indicating the proportion of the population experiencing a reassessment in each of 149 upper tier local authorities in England between 2010 and 2013. Regression models were used to investigate whether the proportion of the population undergoing reassessment in each area was independently associated with the chances that people out-of-work with a long-standing health problem entered employment and transitions between inactivity and unemployment. We analysed whether any effects differed between people whose main health problem was mental rather than physical.

RESULTS

There was no significant association between the reassessment process and the chances that people out-of-work with a long-standing illness entered employment. The process was significantly associated with an increase in the chances that people with mental illnesses moved from inactivity into unemployment (HR=1.22, 95% CI 1.03 to 1.45).

CONCLUSIONS

The reassessment policy appears to have shifted people with mental health problems from inactivity into unemployment, but there was no evidence that it had increased their chances of employment. There is an urgent need for services that can support the increasing number of people with mental health problems on unemployment benefits.

Effects of the Global Financial Crisis on Health in High-Income Oecd Countries

A growing body of evidence documents how economic crises impact aspects of health across countries and over time. We performed a systematic narrative review of the health effects of the latest economic crisis based on studies of high-income countries. Papers published between January 2009 and July 2015 were selected based on review of titles and abstracts, followed by a full text review conducted by two independent reviewers. Ultimately, 122 studies were selected and their findings summarized. The review finds that the 2008 financial crisis had negative effects on mental health, including suicide, and to a varying extent on some non-communicable and communicable diseases and access to care. Although unhealthy behaviors such as hazardous drinking and tobacco use appeared to decline during the crisis, there have been increases in some groups, typically those already at greatest risk. The health impact was greatest in countries that suffered the largest economic impact of the crisis or prolonged austerity. The Great Recessions in high-income countries have had mixed impacts on health. They tend to be worse when economic impacts are more severe, prolonged austerity measures are implemented, and there are pre-existing problems of substance use among vulnerable groups.

Quantifying the impact of rising food prices on child mortality in India: a cross-district statistical analysis of the District Level Household Survey

BACKGROUND

Rates of child malnutrition and mortality in India remain high. We tested the hypothesis that rising food prices are contributing to India's slow progress in improving childhood survival.

METHODS

Using rounds 2 and 3 (2002-08) of the Indian District Level Household Survey, we calculated neonatal, infant and under-five mortality rates in 364 districts, and merged these with district-level food price data from the National Sample Survey Office. Multivariate models were estimated, stratified into 27 less deprived states and territories and 8 deprived states ('Empowered Action Groups').

RESULTS

Between 2002 and 2008, the real price of food in India rose by 11.7%. A 1% increase in total food prices was associated with a 0.49% increase in neonatal (95% confidence interval (CI): 0.13% to 0.85%), but not infant or under-five mortality rates. Disaggregating by type of food and level of deprivation, in the eight deprived states, we found an elevation in neonatal mortality rates of 0.33% for each 1% increase in the price of meat (95% CI: 0.06% to 0.60%) and 0.10% for a 1% increase in dairy (95% CI: 0.01% to 0.20%). We also detected an adverse association of the price of dairy with infant (b = 0.09%; 95% CI: 0.01% to 0.16%) and under-five mortality rates (b = 0.10%; 95% CI: 0.03% to 0.17%). These associations were not detected in less deprived states and territories.

CONCLUSIONS

Rising food prices, particularly of high-protein meat and dairy products, were associated with worse child mortality outcomes. These adverse associations were concentrated in the most deprived states.

Austerity and Abortion in the European Union

Economic hardship accompanying large recessions can lead families to terminate unplanned pregnancies. To assess whether abortions have risen during the recession, we collected crude abortion data from 2000 to 2012 from Eurostat for countries that had legal abortions and complete data. Declining trends in abortion ratios between 2000 and 2009 have been reversing. Excess abortions between 2010 and 2012 totaled 10.6 abortions per 1000 pregnancies ending in abortion or birth or 6701 additional abortions (95% CI 1190–9240) with stronger effects in younger ages. Economic shocks may increase recourse to abortion. Further research should explore causal pathways and protective factors.

Breastfeeding, pregnant, and non-breastfeeding nor pregnant women's food consumption: A matched within-household analysis in India

OBJECTIVE

Promoting breastfeeding is major maternal and child health goal in India. It is unclear whether mothers receive additional food needed to support healthy breastfeeding.

METHODS

Using the latest National Family and Health Survey (2005-2006), we applied multilevel linear regression models to document correlates of nutrition for (n = 20,764) breastfeeding women. We then compared consumption of pulses, eggs, meat, fish, dairy, fruit, and vegetables across a sample of breastfeeding, non-breastfeeding/pregnant (NBP), and pregnant women (n = 3,409) matched within households and five-year age bands. We tested whether breastfeeding women had greater advantages in the 18 high-focus states of India's National Rural Health Mission (NRHM).

RESULTS

Vegetarianism, caste, and religion were the strongest predictors of breastfeeding women's nutrition. Breastfeeding women had no nutritional advantage compared to NBP women, and were disadvantaged in their consumption of milk (b = -0.14) in low-focus states. Pregnant women were similarly disadvantaged in their consumption of milk in low-focus states (b = -0.32), but consumed vegetables more frequently (b = 0.12) than NBP women in high-focus states.

CONCLUSIONS

Breastfeeding women do not receive nutritional advantages compared to NBP women. Targeted effort is needed to assess and improve nutritional adequacy for breastfeeding Indian women.

'It's The Sun Wot Won It': Evidence of media influence on political attitudes and voting from a UK quasi-natural experiment

Do print media significantly impact political attitudes and party identification? To examine this question, we draw on a rare quasi-natural experiment that occurred when The Sun, a right-leaning UK tabloid, shifted its support to the Labour party in 1997 and back to the Conservative party in 2010. We compared changes in party identification and political attitudes among Sun readers with non-readers and other newspaper readerships. We find that The Sun's endorsements were associated with a significant increase in readers' support for Labour in 1997, approximately 525,000 votes, and its switch back was associated with about 550,000 extra votes for the Conservatives in 2010. Although we observed changes in readers' party preference, there was no effect on underlying political preferences. The magnitude of these changes, about 2% of the popular vote, would have been unable to alter the outcome of the 1997 General Election, but may have affected the 2010 Election.

Suicidality, Economic Shocks, and Egalitarian Gender Norms

Durkheim conceived of suicide as a product of social integration and regulation. Although the sociology of suicide has focused on the role of disintegration, to our knowledge, the interaction between integration and regulation has yet to be empirically evaluated. In this article we test whether more egalitarian gender norms, an important form of macro-regulation, protects men and women against suicidality during economic shocks. Using cross-national data covering 20 European Union countries from the years 1991 to 2011, including the recent economic crises in Europe, we first assessed the relation between unemployment and suicide. Then we evaluated potential effect modification using three measures of gender equality, the gender ratio in labour force participation, the gender pay gap, and women's representation in parliament using multiple measures. We found no evidence of a significant, direct link between greater gender equality and suicide rates in either men or women. However, a greater degree of gender equality helped protect against suicidality associated with economic shocks. At relatively high levels of gender equality in Europe, such as those seen in Sweden and Austria, the relationship between rising unemployment rates and suicide in men disappeared altogether. Our findings suggest that more egalitarian forms of gender regulation may help buffer the suicidal consequences of economic shocks, especially in men.

The revision of the 2014 European tobacco products directive: an analysis of the tobacco industry's attempts to 'break the health silo'

BACKGROUND

The 2014 European Union (EU) Tobacco Products Directive (TPD) was negotiated in a changed policy context, following adoption of the EU's 'Smart Regulation' agenda, which transnational tobacco companies (TTCs) anticipated would increase their influence on health policy, and the WHO Framework Convention on Tobacco Control (FCTC), which sought to reduce it. This study aims to explore the scale and nature of the TTCs' lobby against the EU TPD and evaluate how these developments have affected their ability to exert influence.

METHODS

Analysis of 581 documents obtained through freedom of information requests, 28 leaked Philip Morris International (PMI) documents, 17 TTC documents from the Legacy Library, web content via Google alerts and searches of the EU institutions' websites, plus four stakeholder interviews.

RESULTS

The lobby was massive. PMI alone employed over 160 lobbyists. Strategies mainly used third parties. Efforts to 'Push' (amend) or 'Delay' the proposal and block 'extreme policy options' were partially successful, with plain packaging and point of sales display ban removed during the 3-year delay in the Commission. The Smart Regulation mechanism contributed to changes and delays, facilitating meetings between TTC representatives (including ex-Commission employees) and senior Commission staff. Contrary to Article 5.3, these meetings were not disclosed.

CONCLUSIONS

During the legislative process, Article 5.3 was not consistently applied by non-health Directorates of the European Commission, while the tools of the Smart Regulation appear to have facilitated TTC access to, and influence on, the 2014 TPD. The use of third parties undermines Article 5.3.

Reflective Practice: How the World Bank Explored Its Own Biases?

While many international organisations have independent evaluations, including the International Monetary Fund (IMF) and World Health organization (WHO), uniquely the World Bank in its 2015 World Development Report sought to ascertain the potential biases that influence how its staff interpret evidence and influence policy. Here, we describe the World Bank's study design, including experiments to ascertain the impact on Bank staff's judgements of complexity, confirmation bias, sunk cost bias, and an understanding of the wishes of those whom they seek to help. We then review the Bank's proposed mechanisms to minimise the impact of the biases they identified. We argue that this approach, that we refer to as 'reflective practice,' deserves to be adopted more widely among institutions that seek to use evidence from research to inform policy and practice.

How do economic crises affect migrants' risk of infectious disease? A systematic-narrative review

BACKGROUND

It is not well understood how economic crises affect infectious disease incidence and prevalence, particularly among vulnerable groups. Using a susceptible-infected-recovered framework, we systematically reviewed literature on the impact of the economic crises on infectious disease risks in migrants in Europe, focusing principally on HIV, TB, hepatitis and other STIs.

METHODS

We conducted two searches in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, websites of key organizations and grey literature to identify how economic changes affect migrant populations and infectious disease. We perform a narrative synthesis in order to map critical pathways and identify hypotheses for subsequent research.

RESULTS

The systematic review on links between economic crises and migrant health identified 653 studies through database searching; only seven met the inclusion criteria. Fourteen items were identified through further searches. The systematic review on links between economic crises and infectious disease identified 480 studies through database searching; 19 met the inclusion criteria. Eight items were identified through further searches. The reviews show that migrant populations in Europe appear disproportionately at risk of specific infectious diseases, and that economic crises and subsequent responses have tended to exacerbate such risks. Recessions lead to unemployment, impoverishment and other risk factors that can be linked to the transmissibility of disease among migrants. Austerity measures that lead to cuts in prevention and treatment programmes further exacerbate infectious disease risks among migrants. Non-governmental health service providers occasionally stepped in to cater to specific populations that include migrants.

CONCLUSIONS

There is evidence that migrants are especially vulnerable to infectious disease during economic crises. Ring-fenced funding of prevention programs, including screening and treatment, is important for addressing this vulnerability.

'First, do no harm': are disability assessments associated with adverse trends in mental health? A longitudinal ecological study

Background

In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit had their eligibility reassessed using a new functional checklist—the Work Capability Assessment. Doctors and disability rights organisations have raised concerns that this has had an adverse effect on the mental health of claimants, but there are no population level studies exploring the health effects of this or similar policies.

Method

We used multivariable regression to investigate whether variation in the trend in reassessments in each of 149 local authorities in England was associated with differences in local trends in suicides, self-reported mental health problems and antidepressant prescribing rates, while adjusting for baseline conditions and trends in other factors known to influence mental ill-health.

Results

Each additional 10 000 people reassessed in each area was associated with an additional 6 suicides (95% CI 2 to 9), 2700 cases of reported mental health problems (95% CI 548 to 4840), and the prescribing of an additional 7020 antidepressant items (95% CI 3930 to 10100). The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities.

Conclusions

The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. This policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

'Normal' serum sodium concentration among inpatients over 65 admitted to hospital: an observational study

BACKGROUND

The usual reference range of serum sodium (typically 135-145 mmol/l) is derived from healthy populations but may not apply to hospital patients.

OBJECTIVES

To describe the range of serum sodium in inpatients and outpatients of both sexes at different ages. To ascertain correlates of serum sodium among older inpatients. To describe the association between sodium and mortality.

METHODS

We used routine hospital data on serum sodium in inpatients admitted between 1 January 2011 and 31 December 2014 and patients attending outpatient or community clinics with no record of admission to the same hospitals in the same period. We investigated the distribution of sodium values within these groups and explored the relationship between serum sodium and death using logistic regression.

RESULTS

Levels among hospital inpatients were significantly lower than in outpatients of the same age. Emergency admissions had lower levels and those admitted from care homes higher levels, risk of inhospital death began to rise at 140 mmol/L, well within the 'normal' range. Patients with a serum sodium concentration of 145 mmol/L on admission have a risk of inhospital death 3.7 times higher than that of a patient with a concentration of 140 mmol/L.

CONCLUSIONS

The range for serum sodium concentration on admission in inpatients is broader and lower than the commonly accepted reference range. The risk of mortality increases at sodium concentration >139 mmol/L, well within reference range currently considered normal.

The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market: a natural experiment contrasting Vietnam and the Philippines

Background

Trade and investment liberalization may facilitate the spread of sugar-sweetened carbonated beverages (SSCBs), products associated with increased risk factors for obesity, type II diabetes, and cardiovascular diseases (Circulation 121:1356–1364, 2010). Apart from a limited set of comparative cross-national studies, the majority of analyses linking liberalization and the food environment have drawn on case studies and descriptive accounts. The current failure of many countries to reverse the obesity epidemic calls for investigation into both individual and systemic factors, including trade and investment policies.

Methods

Using a natural experimental design we tested whether Vietnam’s removal of restrictions on foreign direct investment (FDI) subsequent to its accession to the World Trade Organization in 2007 increased sales of SSCBs compared with a matched country, the Philippines, which acceded in 1995. Difference-in-difference (DID) models were used to test pre/post differences in total SSCB sales and foreign company penetration covering the years 1999–2013.

Results

Following Vietnam’s removal of restrictions on FDI, the growth rate of SSCB sales increased to 12.1 % per capita per year from a prior growth rate of 3.3 %. SSCB sales per capita rose significantly faster pre- and post-intervention in Vietnam compared with the control country the Philippines (DID: 4.6 L per annum, 95 % CI: 3.8 to 5.4 L, p < 0.008). Vietnam’s increase in SSCBs was primarily attributable to products manufactured by foreign companies, whose annual sales growth rates rose from 6.7 to 23.1 %, again unmatched within the Philippines over this period (DID: 12.3 %, 95 % CI: 8.6 to 16.0 %, p < 0.049).

Conclusions

Growth of SSCB sales in Vietnam, led by foreign-owned companies, significantly accelerated after trade and investment liberalization.