What (or who) causes health inequalities: theories, evidence and implications?

Does "Rural" Always Mean the Same? Macrosocial Determinants of Rural Populations' Health in Poland

Rural areas, as well as urban ones, are not homogeneous in terms of social and economic conditions. Those surrounding large urban centers (suburban rural areas) act different roles than those located in remote areas. This study aims to measure the level of inequalities in social determinants of health (SDH) between two categories of rural areas. We pose the following research hypotheses: (hypothesis H1) rural areas in Poland are relatively homogenous in the context of SDH and (hypothesis H2) SDH affects life expectancies of rural residents. Based on data covering all rural territories, we found that rural areas in Poland are homogenous in SDH. We also find important determinants of health rooted in a demographic structure—the feminization index and a ratio of the working-age population. On the other hand, we cannot confirm the influence of commonly used SDH-GDP and unemployment rate.

What's for lunch? The content and quality of lunches consumed by Dutch primary schoolchildren and the differences between lunches consumed at home and at school

Background

Lunch is an important part of a healthy diet, which is essential for the development, growth and academic performance of school-aged children. Currently there is an increasing number of Dutch primary schoolchildren who are transitioning from eating lunch at home to school. There is limited knowledge about the current quality of the lunches consumed by primary schoolchildren in the Netherlands and whether there are any differences between lunches consumed at home or at school. To investigate differences in content and quality of lunches consumed by Dutch primary schoolchildren at home and at school.

Methods

Cross-sectional study among 363 Dutch primary schoolchildren aged 4–12 years based on the first two years of the 2012–2016 Dutch National Food Consumption Survey. Demographic characteristics were obtained through a questionnaire. Diet was assessed with two non-consecutive 24-h dietary recalls. Quality of lunches was assessed on their nutritional quality whether they fitted the nutritional guidelines. ‘Nonparametric tests were used to examine the content and quality of the lunches between place of consumption and parental educational position.

Results

The most consumed lunch products among primary schoolchildren were bread, dairy products and sugar-sweetened beverages. Fruit and vegetable consumption was very low. Consumption of milk and other dairy products was higher among children who eat lunch at home than children who eat lunch at school (p < 0.01). Consumption of sugar-sweetened beverages was higher among children who eat lunch at school than children who eat lunch at home (p < 0.01), and at school a higher proportion of the drinks did not fit within the Dutch dietary recommendations (p < 0.01).

Conclusions

The current content of the lunches consumed by Dutch primary schoolchildren leaves room for improvement, especially regarding fruit and vegetables. The statistically significantly higher consumption of sugar-sweetened beverages and lower consumption of milk and dairy products at school vs. home is worrisome, as currently more children in the Netherlands are transitioning to having lunch at school.

Relationship between childhood socioeconomic position and adverse childhood experiences (ACEs): a systematic review

BACKGROUND

'Adverse childhood experiences' (ACEs) are associated with increased risk of negative outcomes in later life: ACEs have consequently become a policy priority in many countries. Despite ACEs being highly socially patterned, there has been very little discussion in the political discourse regarding the role of childhood socioeconomic position (SEP) in understanding and addressing them. The aim here was to undertake a systematic review of the literature on the relationship between childhood SEP and ACEs.

METHODS

MEDLINE, PsycINFO, ProQuest and Cochrane Library databases were searched. Inclusion criteria were: (1) measurement of SEP in childhood; (2) measurement of multiple ACEs; (3) ACEs were the outcome; and (4) statistical quantification of the relationship between childhood SEP and ACEs. Search terms included ACEs, SEP and synonyms; a second search additionally included 'maltreatment'. Overall study quality/risk of bias was calculated using a modified version of the Hamilton Tool.

RESULTS

In the ACEs-based search, only 6 out of 2825 screened papers were eligible for qualitative synthesis. The second search (including maltreatment) increased numbers to: 4562 papers screened and 35 included for synthesis. Eighteen papers were deemed 'high' quality, five 'medium' and the rest 'low'. Meaningful statistical associations were observed between childhood SEP and ACEs/maltreatment in the vast majority of studies, including all except one of those deemed to be high quality.

CONCLUSION

Lower childhood SEP is associated with a greater risk of ACEs/maltreatment. With UK child poverty levels predicted to increase markedly, any policy approach that ignores the socioeconomic context to ACEs is therefore flawed.

PROSPERO REGISTRATION NUMBER

CRD42017064781.

Socioeconomic inequalities in non-communicable disease risk factors in Botswana: a cross-sectional study

BACKGROUND

The debate on socioeconomic inequalities in health dominates the research and policy agenda of many countries. The prevalence of non-communicable diseases (NCDs) is on the rise in recent years in Botswana. As a prevention and policy effort, the study provided an empirical evidence on socioeconomic inequalities in NCD risk factors in Botswana.

METHODS

Data used in this study was derived from a cross sectional survey on chronic non communicable diseases in Botswana conducted in 2016. The survey adopted a multistage sampling design and a sample of 1178 participants (males and females) aged 15 years and above was selected in both urban and rural areas of Botswana. The inequality analysis was conducted employing decomposition analysis using ADePT software version 6. Logistic regression models were used to show the association between NCD risk factors and socioeconomic status using SPSS version 25.

RESULTS

Concentration indices showed that poor physical activity (CI = 0.0546), alcohol consumption (CI = 0.1859) and overweight/obesity (CI = 0.038) were more concentrated among the non-poor while daily smoking (CI = - 0.0308) and poor fruit/vegetable consumption (CI = - 0.1909) were more concentrated among the poor. Wealth status was observed to be the leading contributor to socioeconomic inequality for daily smoking, poor fruit/vegetable consumption, overweight/obesity and poor physical activity. Education was the leading contributor to socioeconomic inequality for alcohol consumption.

CONCLUSIONS

Findings in this study indicate the need for concerted differential efforts to address the needs of the poor and non-poor in order to reduce NCD risk factor inequalities.

Reframing inequality? The health inequalities turn as a dangerous frame shift

Background

Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but European governments have for the most part failed to enact policies that would reduce underlying social inequalities.

Methods

Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health inequalities policies.

Results

Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.

Conclusions

Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.

Defining health and health inequalities

OBJECTIVES

To examine existing definitions of health and health inequalities and to synthesise the most useful of these using explicit rationale and the most parsimonious text.

STUDY DESIGN

Literature review and synthesis.

METHODS

Existing definitions of health and health inequalities were identified, and their normative properties were extracted and then critically appraised. Using explicit reasoning, new definitions, synthesising the most useful aspects of existing definitions, were created.

RESULTS

A definition of health as a structural, functional and emotional state that is compatible with effective life as an individual and as a member of society and a definition of health inequalities as the systematic, avoidable and unfair differences in health outcomes that can be observed between populations, between social groups within the same population or as a gradient across a population ranked by social position are proposed. Population health is a less commonly used term but can usefully be defined to encompass the average, distribution and inequalities in health within a society.

CONCLUSIONS

Clarifying what is meant by the terms health and health inequalities, and the assumptions, emphasis and values that different definitions contain, is important for public health research, practice and policy.

Educational inequalities in self-rated health and social relationships - analyses based on the European Social Survey 2002-2016

BACKGROUND

While there is evidence for educational health inequalities in Europe, studies on time trends and on the explanatory contribution of social relations are less consistent. It has been shown that the use of welfare state typologies can be helpful to examine health inequalities in a comparative perspective. Against this background, analyses are focused on three research questions: (1) How did educational inequalities in self-rated health (SRH) develop between 2002 and 2016 in different European countries? (2) In how far can structural and functional aspects of social relations help to explain these inequalities? (3) Do these explanatory contributions vary between different types of welfare states?

METHODS

Data stem from the European Social Survey. Data from 20 countries across 8 waves (2002-2016) was included in the sample (allocated to 5 types of welfare states). Structural aspects of social relations were measured by living with a partner, frequency of social contacts and social participation. Availability of emotional support was used as functional dimension. Educational level was assessed based on the International Standard Classification of Education. SRH was measured in all waves on a five-point scale by one question: "How is your health in general? Would you say it is very good, good, fair, bad or very bad?"

RESULTS

Across all countries, educational inequalities were increasing between 2002 and 2016. Explanatory contribution of emotional support, living with a partner, and social contacts was small (5% or less across the eight waves). Social participation explained 11% of the educational inequalities in SRH in the European countries. There were small variations in the explanatory contribution of social participation between welfare states.

CONCLUSIONS

Promoting social participation, especially of people with low education is a possible intervention to reduce inequalities in SRH in Europe.

Health inequality implications from a qualitative study of experiences of poverty stigma in Scotland

Rationale

Individuals living in Scotland's most deprived communities experience a higher burden of morbidity and early mortality than those living in more affluent areas. Experiences of poverty-based stigma may be one psychosocial mechanism through which socioeconomic position influences health, although there is little available data on this issue from a Scottish perspective.

Objective

The aim of this study was to identify which aspects of poverty stigma are particularly salient to individuals with lived experience of poverty, and may therefore contribute to health inequalities.

Methods

Five focus groups were conducted with 39 individuals with experience of living on low incomes in Scotland in order to explore their experiences and perceptions of poverty stigma.

Results

Five main themes were identified, reflecting aspects of poverty stigma operating at various structural, public and individual levels: media representations of poverty; negative encounters with social security systems; perceived public attitudes regarding poverty in Scotland; lowered self-esteem and internalisation of negative attitudes, and; emotional responses to stigma.

Conclusion

These dimensions of stigma potentially influence public health and health inequalities in Scotland, although future research will be necessary to quantify these and estimate their relationships with health outcomes.

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Relatively little is currently known about poverty-based stigma in Scotland.

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People with experience of poverty discussed this issue in five focus groups.

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Participants' accounts reflected several forms of poverty stigma.

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Poverty stigma operates at various structural, social, and individual levels.

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Poverty stigma is a potentially important determinant of health inequalities.

Contribution to healthy places: Risks of equity free health impact assessment

While health equity is central to health impact assessment [HIA], in reality, less is known about potential impacts of equity-free HIA on social inequalities. We assessed equity-free HIA case in a small city east of Montreal, which took place in a context of urban revitalization. We applied a combination of a quantitative review of community characteristics with a qualitative descriptive approach based on in-depth semi-structured interviews and a focus group with multiple stakeholders to shed light on the pitfalls of equity-free HIA. Our results pointed to gentrification process with a gradual relocation of low-income residents in the end. To mitigate mediating circumstances of gentrification and displacement, the municipality should support social housing or at least should ensure rent stabilization ordinance.

Theorising social class and its application to the study of health inequalities

The literature on health inequalities often uses measures of socio-economic position pragmatically to rank the population to describe inequalities in health rather than to understand social and economic relationships between groups. Theoretical considerations about the meaning of different measures, the social processes they describe, and how these might link to health are often limited. This paper builds upon Wright's synthesis of social class theories to propose a new integrated model for understanding social class as applied to health. This model incorporates several social class mechanisms: social background and early years' circumstances; Bourdieu's habitus and distinction; social closure and opportunity hoarding; Marxist conflict over production (domination and exploitation); and Weberian conflict over distribution. The importance of discrimination and prejudice in determining the opportunities for groups is also explicitly recognised, as is the relationship with health behaviours. In linking the different social class processes we have created an integrated theory of how and why social class causes inequalities in health. Further work is required to test this approach, to promote greater understanding of researchers of the social processes underlying different measures, and to understand how better and more comprehensive data on the range of social class processes these might be collected in the future.

Social gradients in health and social care costs: Analysis of linked electronic health records in Kent, UK

OBJECTIVES

Research into the socio-economic patterning of health and social care costs in the UK has so far been limited to examining only particular aspects of healthcare. In this study, we explore the social gradients in overall healthcare and social care costs, as well as in the disaggregated costs by cost category.

STUDY DESIGN

We calculated the social gradient in health and social care costs by cost category using a linked electronic health record data set for Kent, a county in South East England. We performed a cross-sectional analysis on a sample of 323,401 residents in Kent older than 55 years to assess the impact of neighbourhood deprivation on mean annual per capita costs in 2016/17.

METHODS

Patient-level costs were estimated from activity data for the financial year 2016/17 and were extracted alongside key patient characteristics. Mean costs were calculated for each area deprivation quintile based on the index of multiple deprivation of the neighbourhood (lower super output area) in which the patient lived. Cost subcategories were analysed across primary care, secondary care, social care, community care and mental health.

RESULTS

The mean annual per capita cost increased with deprivation across each deprivation quintile, with a cost of £1205 in the most affluent quintile, compared with £1623 in the most deprived quintile, a 35% cost increase. Social gradients were found across all cost subcategories.

CONCLUSIONS

Health inequalities in the population older than 55 years in Kent are associated with health and social care costs of £109m, equivalent to 15% of the estimated total expenditure in this age group. Such significant costs suggest that appropriate interventions to reduce socio-economic inequalities have the potential to substantially improve population health and, depending on how much investment they require, may even result in cost savings.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

Social Determinants of Mental Health: Where We Are and Where We Need to Go

PURPOSE OF REVIEW

The present review synthesizes recent literature on social determinants and mental health outcomes and provides recommendations for how to advance the field. We summarize current studies related to changes in the conceptualization of social determinants, how social determinants impact mental health, what we have learned from social determinant interventions, and new methods to collect, use, and analyze social determinant data.

RECENT FINDINGS

Recent research has increasingly focused on interactions between multiple social determinants, interventions to address upstream causes of mental health challenges, and use of simulation models to represent complex systems. However, methodological challenges and inconsistent findings prevent a definitive understanding of which social determinants should be addressed to improve mental health, and within what populations these interventions may be most effective. Recent advances in strategies to collect, evaluate, and analyze social determinants suggest the potential to better appraise their impact and to implement relevant interventions.

Education, cognitive ability, and cause-specific mortality: A structural approach

Education is negatively associated with most major causes of death. Prior work ignores the premise that cause-specific hazards are interdependent and that both education and mortality depend on cognitive ability. We analyse Swedish men aged 18-63, focusing on months lost due to specific causes-which solves the interdependence problem-and use a structural model that accounts for confounding due to cognitive ability. In a standard Cox model controlling for Intelligence Quotient, improving education is associated with large decreases in mortality for major causes of death. In the structural model, improving education is associated with a small decrease in months lost for most causes and education levels. Among the least educated, however, improving education strongly reduces the months lost, mainly those lost from external causes, such as accidents and suicide. Results suggest that conventional analysis of education and mortality may be biased, even if accounting for observed cognition.

How do health behaviour interventions take account of social context? A literature trend and co-citation analysis

In recent years, health behaviour interventions have received a great deal of attention in both research and policy as a means of encouraging people to lead healthier lives. The emphasis of such interventions has varied over time, in terms of level of intervention (e.g. individual vs community) and drawing on different disciplinary perspectives. Recently, a number of critiques have focused on how health behaviour interventions sometimes sideline issues of social context, framing health as a matter of individual choice and, by implication, a personal responsibility. Part of this criticism is that health behaviour interventions often do not draw on alternative social science understandings of the structured and contextual aspects of behaviour and health. Yet to our knowledge, no study has attempted to empirically assess the extent to which, and in what ways, the health behaviour intervention field has paid attention to social context. In this article, we undertake this task using bibliometric techniques in order to map out the health behaviour intervention field. We find that the number of health behaviour interventions has grown rapidly in recent years, especially since around 2006, and that references to social science disciplines and concepts that foreground issues of social context are rare and, relatively speaking, constitute less of the field post 2006. More quantifiable concepts are used most, and those more close to the complexities of social context are mentioned least. The document co-citation analysis suggests that pre 2006, documents referring to social context were relatively diffuse in the network of key citations, but post 2006 this influence had largely diminished. The journal co-citation analysis shows less disciplinary overlap post 2006. At present, health behaviour interventions are continuing to focus on individualised approaches drawn from behavioural psychology and behavioural economics. Our findings lend empirical support to a number of recent papers that suggest more interdisciplinary collaboration is needed to advance the field.

Differentiating the effect of social enterprise activities on health

An emerging stream of literature has focused on the ways in which social enterprises might act on the social determinants of health. However, this previous work has not taken a sufficiently broad account of the wide range of stakeholders involved in social enterprises and has also tended to reduce and simplify a complex and heterogeneous set of organisations to a relatively homogenous social enterprise concept. In an attempt to address these gaps, we conducted an empirical investigation between August 2014 and October 2015 consisting of qualitative case studies involving in-depth semi-structured interviews and a focus group with a wide variety of stakeholders from three social enterprises in different regions of Scotland. We found that different forms of social enterprise impact on different dimensions of health in different ways, including through: engendering a feeling of ownership and control; improving environmental conditions (both physical and social); and providing or facilitating meaningful employment. In conclusion, we highlight areas for future research.

Unequal distribution of health human resource in mainland China: what are the determinants from a comprehensive perspective?

Background

The inequality of health human resource is a worldwide problem, and solving it also is one of the major goals of China’s recent health system reform. Yet there is a huge disparity among cities in mainland China. The aim of this study is to analyze the distribution inequality of the health human resource in 322 prefecture-level cities of mainland China in 2014, and to reveal the facets and causes of the inequalities.

Methods

The data for this study were acquired from the provincial and municipal Health Statistics Yearbook (2014) and Statistical Yearbook (2014), the municipal National Economic Bulletin (2014), and the official websites of municipal governments, involving 322 prefecture-level cities. Meanwhile, Concentration Index was used to measure the magnitude of the unequal distribution of health human resource. A decomposition analysis was employed to quantify the contribution of each determinant to the total inequality.

Results

The overall concentration index of doctors and nurses in mainland China in 2014 was 0.1038 (95% CI = 0.0208, 0.1865) and 0.0785 (95% CI =0.0018, 0.1561). Decomposition of the concentration index revealed that economic status was the primary contributor (58.5% and 57%) to the inequality of doctors and nurses, followed by the Southwest China (19.1% and 18.6%), urbanization level (− 13.1% and − 12.8%), and revenue (8.0% and 7.8%). Party secretaries with Master degree (7.0%, 6.8%), mayors who were 60 years old or above (6.3%, 6.1%) also were proved to be a major contributor to the inequality of health human resource.

Conclusions

There was inequality of health human resource distribution which was pro-rich in mainland China in 2014. Economic status of the cities accounted for most of the existing inequality, followed by the Southwest China, urbanization level, revenue, party secretaries with Master degree, and mayors who were 60 years old or above in respective importance. Besides, the party secretaries and mayors also had certain influence on the allocation of health human resource. The tough issue of HHR inequality should be addressed by comprehensive measures from a multidisciplinary perspective.

Threat of Deportation as Proximal Social Determinant of Mental Health Amongst Migrant Workers

While migration health studies traditionally focused on socioeconomic determinants of health, an emerging body of literature is exploring migration status as a proximate cause of health outcomes. Study 1 is a path analysis of the predictors of mental health amongst 582 documented migrant workers in Singapore, and shows that threat of deportation is one of the most important proximate social determinants of predicted mental illness, and a mediator of the impact of workplace conflict on mental health. Study 2 is a qualitative study of the narratives of 149 migrant workers who were in workplace conflict with their employers, and demonstrates that workers believed threats were used as a negotiating strategy during workplace conflicts. Findings suggest that migration status places workers who come into workplace conflict with their employers at heightened risk of mental illness because migration status can be used as a tool by employers in workplace negotiations.

Do patients who die from an alcohol-related condition 'drift' into areas of greater deprivation? Alcohol-related mortality and health selection theory in Scotland

Background

Health selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes.

Methods

Deaths recorded in Scotland (2013, >21 years) were coded as ‘alcohol-related’ or ‘other’ and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. χ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest.

Results

Of 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified ‘alcohol-related’ among cases whose deprivation score decreased, while 204 more deaths than expected were classified ‘alcohol-related’ among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders.

Conclusion

This study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual’s initial area deprivation category.

How do trends in mortality inequalities by deprivation and education in Scotland and England & Wales compare? A repeat cross-sectional study

OBJECTIVE

To compare the trends in mortality inequalities by educational attainment with trends using area deprivation.

SETTING

Scotland and England & Wales (E&W).

PARTICIPANTS

All people resident in Scotland and E&W between 1981 and 2011 aged 35-79 years.

PRIMARY OUTCOME MEASURES

Absolute inequalities (measured using the Slope Index of Inequality (SII)) and relative inequalities (measured using the Relative Index of Inequality (RII)) in all-cause mortality.

RESULTS

Relative inequalities in mortality by area deprivation have consistently increased for men and women in Scotland and E&W between 1981-1983 and 2010-2012. Absolute inequalities increased for men and women in Scotland, and for women in E&W, between 1981-1983 and 2000-2002 before subsequently falling. For men in E&W, absolute inequalities were more stable until 2000-2002 before a subsequent decline. Both absolute and relative inequalities were consistently higher in men and in Scotland. These trends contrast markedly with the reported declines in mortality inequalities by educational attainment and apparent improvement of Scotland's inequalities with those in E&W.

CONCLUSIONS

Trends in health inequalities differ when assessed using different measures of socioeconomic status, reflecting either genuinely variable trends in relation to different aspects of social stratification or varying error or bias. There are particular issues with the educational attainment data in Great Britain prior to 2001 that make these education-based estimates less certain.

Can targeted policies reduce obesity and improve obesity-related behaviours in socioeconomically disadvantaged populations? A systematic review

This review synthesized evidence from controlled studies pertaining to the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged children and adults. Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity guidelines were followed. Eligible studies were published from 2004 to August 2015 and examined the impact of targeted policies on anthropometric, dietary and physical activity outcomes amongst socioeconomically disadvantaged populations. Twenty articles (18 studies) were included. Eight studies examined organizational policies within multi-component interventions in schools. Common elements of successful policy-containing interventions included nutritional standards, enhancements to physical education, additional physical activity opportunities, school self-assessments, and nutrition and physical activity education. Of the 10 studies of government policies, policies providing information/education and fruit and vegetable subsidies had positive impacts amongst children, but no impact amongst adults. Policies involving changes to built environments yielded nearly uniformly null findings in children and adults. Overall, the largest quantity of high-quality evidence of effectiveness was for comprehensive interventions that included school policies, and government policies targeting disadvantaged children in schools. None of the government policies targeting disadvantaged adults proved effective. Interventions during childhood may ameliorate negative obesity-related manifestations of socioeconomic disadvantage. Gaps in knowledge remain surrounding effective policies in adults, adolescents and very young children.

Health promotion in school environment in Brazil

OBJECTIVE

Evaluate the school environments to which ninth-year students are exposed in Brazil and in the five regions of the country according to health promotion guidelines.

METHODS

Cross-sectional study from 2012, with a representative sample of Brazil and its macroregions. We interviewed ninth-year schoolchildren and managers of public and private schools. We proposed a score of health promotion in the school environment (EPSAE) and estimated the distribution of school members according to this score. Crude and adjusted odds ratios (OR) were used, by ordinal regression, to determine the schoolchildren and schools with higher scores, according to the independent variables.

RESULTS

A student is more likely to attend a school with a higher EPSAE in the South (OR = 2.80; 95%CI 2.67–2.93) if the school is private (OR = 4.52; 95%CI 4.25–4.81) and located in a state capital, as well as if the student is 15 years of age or older, has a paid job, or has parents with higher education.

CONCLUSIONS

The inequalities among the country’s regions and schools are significant, demonstrating the need for resources and actions that promote greater equity.

Increasing inequality in age of death at shared levels of life expectancy: A comparative study of Scotland and England and Wales

There is a strong negative correlation between increasing life expectancy and decreasing lifespan variation, a measure of inequality. Previous research suggests that countries achieving a high level of life expectancy later in time generally do so with lower lifespan variation than forerunner countries. This may be because they are able to capitalise on lessons already learnt. However, a few countries achieve a high level of life expectancy later in time with higher inequality. Scotland appears to be such a country and presents an interesting case study because it previously experienced lower inequality when reaching the same level of life expectancy as its closest comparator England and Wales. We calculated life expectancy and lifespan variation for Scotland and England and Wales for the years 1950 to 2012, comparing Scotland to England and Wales when it reached the same level of life expectancy later on in time, and assessed the difference in the level of lifespan variation. The lifespan variation difference between the two countries was then decomposed into age-specific components. Analysis was carried out for males and females separately. Since the 1950s Scotland has achieved the same level of life expectancy at least ten years later in time than England and Wales. Initially it did so with lower lifespan variation. Following the 1980s Scotland has been achieving the same level of life expectancy later in time than England and Wales and with higher inequality, particularly for males. Decomposition revealed that higher inequality is partly explained by lower older age mortality rates but primarily by higher premature adult age mortality rates when life expectancy is the same. Existing studies suggest that premature adult mortality rates are strongly associated with the social determinants of health and may be amenable to social and economic policies. So addressing these policy areas may have benefits for both inequality and population health in Scotland.

Is there a link between childhood adversity, attachment style and Scotland's excess mortality? Evidence, challenges and potential research

Background

Scotland has a persistently high mortality rate that is not solely due to the effects of socio-economic deprivation. This “excess” mortality is observed across the entire country, but is greatest in and around the post-industrial conurbation of West Central Scotland. Despite systematic investigation, the causes of the excess mortality remain the subject of ongoing debate.

Discussion

Attachment processes are a fundamental part of human development, and have a profound influence on adult personality and behaviour, especially in response to stressors. Many studies have also shown that childhood adversity is correlated with adult morbidity and mortality.

The interplay between childhood adversity and attachment is complex and not fully elucidated, but will include socio-economic, intergenerational and psychological factors. Importantly, some adverse health outcomes for parents (such as problem substance use or suicide) will simultaneously act as risk factors for their children.

Data show that some forms of “household dysfunction” relating to childhood adversity are more prevalent in Scotland: such problems include parental problem substance use, rates of imprisonment, rates of suicide and rates of children being taken into care. However other measures of childhood or family wellbeing have not been found to be substantially different in Scotland compared to England.

Summary

We suggest in this paper that the role of childhood adversity and attachment experience merits further investigation as a plausible mechanism influencing health in Scotland. A model is proposed which sets out some of the interactions between the factors of interest, and we propose parameters for the types of study which would be required to evaluate the validity of the model.

The Israeli Medical Association's discourse on health inequity

The present paper analyses the emergence and characteristics of Israeli Medical Association (IMA) discourse on health inequality in Israel during the years 1977-2010. The IMA addressed the issue of health inequality at a relatively late stage in time (2000), as compared to other OECD countries such as the UK, and did so in a relatively limited way, focusing primarily on professional or economic interests. The dominant discourses on health inequalities within the IMA are biomedical and behavioral, characterized by a focus on medical and/or cultural and behavioral differences, the predominant use of medical terminology, and an individualistic rather than a structural conceptualization of the social characteristics of health differences. Additionally, IMA discourses emphasize certain aspects of health inequality such as the geographical and material inequities, and in doing so overlook the role played by class, nationality and the unequal structure of citizenship. Paradoxically, by disregarding the latter, the IMA's discourse on health inequality has the potential to reinforce the structural causes of these inequities. Our research is based on a textual critical discourse analysis (CDA) of hundreds of documents from the IMA's scientific medical journal, the IMA's members journal and public IMA documents such as press-releases, Knesset protocols, publications, and public surveys. By providing knowledge on the different ways in which the IMA, a key stakeholder in the health field, de-codifies, understands, explains, and attempts to deal with health inequality, the article illuminates possible implications on health policy and seeks to evaluate the direct interventions carried out by the IMA, or by other actors influenced by it, pertaining to health inequality.

Inequalities in health: definitions, concepts, and theories

Individuals from different backgrounds, social groups, and countries enjoy different levels of health. This article defines and distinguishes between unavoidable health inequalities and unjust and preventable health inequities. We describe the dimensions along which health inequalities are commonly examined, including across the global population, between countries or states, and within geographies, by socially relevant groupings such as race/ethnicity, gender, education, caste, income, occupation, and more. Different theories attempt to explain group-level differences in health, including psychosocial, material deprivation, health behavior, environmental, and selection explanations. Concepts of relative versus absolute; dose-response versus threshold; composition versus context; place versus space; the life course perspective on health; causal pathways to health; conditional health effects; and group-level versus individual differences are vital in understanding health inequalities. We close by reflecting on what conditions make health inequalities unjust, and to consider the merits of policies that prioritize the elimination of health disparities versus those that focus on raising the overall standard of health in a population.

What is the association of smoking and alcohol use with the increase in social inequality in mortality in Denmark? A nationwide register-based study

OBJECTIVES

The aim of this paper is to estimate the impact of smoking and alcohol use on the increase in social inequality in mortality in Denmark in the period 1985-2009.

DESIGN

A nationwide register-based study.

SETTING

Denmark.

PARTICIPANTS

The whole Danish population aged 30 years or more in the period 1985-2009.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is mortality rates in relation to educational attainments calculated with and without deaths related to smoking and alcohol use. An absolute measure of inequality in mortality is applied along with a result on the direct contribution from smoking and alcohol use on the absolute difference in mortality rates. The secondary outcome is life expectancy in relation to educational attainments.

RESULTS

Since 1985, Danish overall mortality rates have decreased. Alongside the improvement in mortality, the absolute difference in the mortality rate (per 100,000 persons) between the lowest and the highest educated quartile grew from 465 to 611 among men and from 250 to 386 among women. Smoking and alcohol use have caused 75% of the increase among men and 97% of the increase among women. Among men the increase was mainly caused by alcohol. In women the increase was mainly caused by smoking.

CONCLUSIONS

The main explanation for the increase in social inequality in mortality since the mid-1980s is smoking and alcohol use. A significant reduction in the social inequality in mortality can only happen if the prevention of smoking and alcohol use are targeted to the lower educated part of the Danish population.

How robust is the calculation of health inequality trends by educational attainment in England and Wales using the Longitudinal Study?

BACKGROUND AND OBJECTIVES

Inequalities in mortality by educational attainment are wider in Eastern Europe than in West and Central Europe, but have thus far been largely limited to cross-sectional analyses. This study explored the potential to use the Longitudinal Study to describe trends in mortality inequality by educational attainment in England and Wales from 1971 to 2009 and the limitations in the available data.

STUDY DESIGN

Comparison of cohort studies.

METHODS

Data from the Office for National Statistics Longitudinal Study were used which takes a sample of respondees from each Census (1971-2001) and links them to death certification. Age-standardized mortality was calculated by educational attainment for those aged 25-69 years as was the Relative Index of Inequality and Slope Index of Inequality for men and women for each time period.

RESULTS

Overall mortality declined in all categories of educational attainment for men and women from 1971. Limited data were collected on educational attainment in the Censuses prior to 2001, combined with the high proportion of respondents with missing data or reporting 'no education', meant that estimates of inequalities for the period 1971 to 2000 were very imprecise and likely to be misleading. For 2001-2009, the slope index of inequality was 268 (95% CI 57-478) and relative index of inequality was 0.61 (95% CI 0.13-1.10) for the total population; 354 (95% CI 72-636) and 0.67 (95% CI 0.14-1.21) respectively for men; and 231 (95% CI 72-389) and 0.66 (95% CI 0.21-1.11) respectively for women.

CONCLUSIONS

Limited educational data in the Censuses prior to 2001 makes calculation of mortality inequalities by educational attainment in England and Wales imprecise and potentially misleading. International comparisons and time trend analyses using these data prior to 2001 should be done with great caution.