Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews

Socio-economic differences in healthcare access from a welfare system perspective, Italy: 2007-2010

Inequalities between poorer and wealthier people in accessing healthcare services have been widely studied, but the mechanisms generating them are still to be fully understood. Among these, there is still a lack of evidence of relationships between health prevention/health promotion policies, welfare systems and social differences. We analysed 68 201 females from the PASSI Italian surveillance system for the years 2007-2010. The prevalence of women undergoing Pap testing was used as an example of access to preventive services. An odds ratio gradient was found with regard to different welfare system clusters: the probability of undergoing a screening test is higher for more advanced welfare systems. A strong association was found between having received a letter from the local health unit and having undergone the screening test. Significant differences still exist between high- and low-income women and their access to Italian preventive public services. As we expected, social determinants play an important role in health disparities, as these are also strongly influenced by typologies of welfare systems and by health policies.

Genetics in population health science: strategies and opportunities

Translational research is needed to leverage discoveries from the frontiers of genome science to improve public health. So far, public health researchers have largely ignored genetic discoveries, and geneticists have ignored important aspects of population health science. This mutual neglect should end. In this article, we discuss 3 areas where public health researchers can help to advance translation: (1) risk assessment: investigate genetic profiles as components in composite risk assessments; (2) targeted intervention: conduct life-course longitudinal studies to understand when genetic risks manifest in development and whether intervention during sensitive periods can have lasting effects; and (3) improved understanding of environmental causation: collaborate with geneticists on gene-environment interaction research. We illustrate with examples from our own research on obesity and smoking.

In-work tax credits for families and their impact on health status in adults

BACKGROUND

By improving two social determinants of health (poverty and unemployment) in low- and middle-income families on or at risk of welfare, in-work tax credit for families (IWTC) interventions could impact health status and outcomes in adults.

OBJECTIVES

To assess the effects of IWTCs on health outcomes in working-age adults (18 to 64 years).

SEARCH METHODS

We searched 16 electronic academic databases, including the Cochrane Public Health Group Specialised Register, Cochrane Database of Systematic Reviews (The Cochrane Library 2012, Issue 7), MEDLINE and EMBASE, as well as six grey literature databases between July and September 2012 for records published between January 1980 and July 2012. We also searched key organisational websites, handsearched reference lists of included records and relevant journals, and contacted academic experts.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials and cohort, controlled before-and-after (CBA) and interrupted time series (ITS) studies of IWTCs in working-age adults. Included primary outcomes were: self rated general health; mental health/psychological distress; mental illness; overweight/obesity; alcohol use and tobacco use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in included studies. We contacted study authors to obtain missing information.

MAIN RESULTS

Five studies (one CBA and four ITS) comprising a total of 5,677,383 participants (all women) fulfilled the inclusion criteria and were synthesised narratively. The in-work tax credit intervention assessed in all included studies is the permanent Earned Income Tax Credit in the United States, established in 1975. This intervention distributed nearly USD 62 billion to over 27 million individuals in 2011, and its administration costs were less than one per cent of its total costs. All included studies carried a high risk of bias (especially from confounding and insufficient control for underlying time trends). Due to the small number of (observational) studies and their high risk of bias, we judged this body of evidence to have very low overall quality.One study found that IWTC had no detectable effect on self rated general health and mental health/psychological distress five years after its implementation (i.e. a considerable change in the generosity of the permanent IWTC) and on overweight/obesity eight years after implementation. One study found no effect of IWTC on tobacco use five years after implementation, one a moderate reduction in tobacco use one year after implementation (odds ratio 0.95, 95% confidence interval (CI) 0.94 to 0.96), and one differential effects, with no effect in African-Americans and a large reduction in European-Americans two years after implementation (risk difference -11.1%, 95% CI -20.9% to -1.3%). No evidence was available for the effect of IWTC on mental illness and alcohol use. No adverse effects of IWTC were identified.One study also found no detectable effect of IWTC on the number of bad physical health days and of risky biomarkers for inflammation, cardiovascular disease and metabolic conditions eight years after implementation. One study found that IWTC had a large, positive effect on income from wages or salaries one year after implementation. Two studies found no effect on employment two and five years after implementation, whereas two found a moderate increase five and eight years after implementation and one a large increase in employment due to IWTC one year after implementation.No differences in outcomes between groups with different educational status were found for self rated health and mental health/psychological distress. In one study European-American women with lower levels of education were more likely to reduce tobacco use, while tobacco use did not change among African-American women with lower levels of education. However, no differences in tobacco use by educational status were observed in a second study. Two studies found that the intervention may have reduced inequity with respect to employment, where women with less education were more likely to move into employment (although one did not establish whether this difference was statistically significant), while two studies found no such difference and no studies found differences by ethnic group on employment rates.

AUTHORS' CONCLUSIONS

In summary, the small and methodologically limited existing body of evidence with a high risk of bias provides no evidence for an effect of in-work tax credit for families interventions on health status (except for mixed evidence for tobacco smoking) in adults.

Assessing the social and physical determinants of circumpolar population health

INTRODUCTION

Systematic reviews of the social and physical determinants of health provide metrics for evaluation of programs to mitigate health disparities. Previous meta-analyses of the population health literature have identified several proximate social and physical determinants of population health in the circumpolar north including addiction, environmental exposures, diet/nutrition and global climate change. Proximate health determinants are most amenable to early detection and modification or mitigation through disease prevention or health promotion interventions.

DESIGN

There is a need for research to replicate these findings based on the latest science. This presentation describes a study applying Dahlgren and Whitehead's (1991) socio-ecological model of health determinants to identify the proximate social and physical determinants of health in the circumpolar north.

METHODS

The study consisted of a systematic review of recent studies that link determinants of health with the leading causes of mortality and morbidity in Alaska. Our search strategy employed a keyword search using the Circumpolar Health Bibliographic Database (CHBD) and 4 databases within the Web of Knowledge (WoK) data gateway. Keywords included various terms for the arctic, all relevant nations and territories within the region, as well as leading health outcomes.

RESULTS

Studies meeting the following inclusion criteria were reviewed: original research within a circumpolar population, published in English during 2011, and involving a rigorous demonstration of a link between a social determinant and selected health outcomes.

CONCLUSIONS

Study conclusions includes a list of determinants identified, their associated outcomes and the study designs implemented to assess that association.

Healthier lives for European minority groups: school and health care, lessons from the Roma

On average, the Roma in Europe can expect to die 10 years earlier than the rest of the population, given the health conditions they experience. EU-funded research has informed on successful actions (SA) that when implemented among the Roma provide them new forms of educational participation which have a direct impact on improving their health status, regardless of their educational level. The findings from this research, unanimously endorsed by the European Parliament, have been included in several European Union recommendations and resolutions as part of the EU strategy on Roma inclusion. To analyze these SA, as well as the conditions that promote them and their impact on reducing health inequalities, communicative fieldwork has been conducted with Roma people from a deprived neighbourhood in the South of Spain, who are participating in the previously identified SA. The analysis reveals that these SA enable Roma people to reinforce and enrich specific strategies like improving family cohesion and strengthening their identity, which allow them to improve their overall health. These findings may inform public policies to improve the health condition of the Roma and other vulnerable groups, one goal of the Europe 2020 strategy for a healthier Europe.

Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns

This essay reviews and evaluates recent comparative social science scholarship on healthcare systems. We focus on four of the strongest themes in current research: (1) the development of typologies of healthcare systems, (2) assessment of convergence among healthcare systems, (3) problematization of the shifting boundaries of healthcare systems, and (4) the relationship between healthcare systems and social inequalities. Our discussion seeks to highlight the central debates that animate current scholarship and identify unresolved questions and new opportunities for research. We also identify five currents in contemporary sociology that have not been incorporated as deeply as they might into research on healthcare systems. These five "missed turns" include an emphasis on social relations, culture, postnational theory, institutions, and causal mechanisms. We conclude by highlighting some key challenges for comparative research on healthcare systems.

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

Health inequalities are the unjust differences in health between groups of people occupying different positions in society. Since the Black Report of 1980 there has been considerable effort to understand what causes them, so as to be able to identify actions to reduce them. This paper revisits and updates the proposed theories, evaluates the evidence in light of subsequent epidemiological research, and underlines the political and policy ramifications. The Black Report suggested four theories (artefact, selection, behavioural/cultural and structural) as to the root causes of health inequalities and suggested that structural theory provided the best explanation. These theories have since been elaborated to include intelligence and meritocracy as part of selection theory. However, the epidemiological evidence relating to the proposed causal pathways does not support these newer elaborations. They may provide partial explanations or insights into the mechanisms between cause and effect, but structural theory remains the best explanation as to the fundamental causes of health inequalities. The paper draws out the vitally important political and policy implications of this assessment. Health inequalities cannot be expected to reduce substantially as a result of policy aimed at changing health behaviours, particularly in the face of wider public policy that militates against reducing underlying social inequalities. Furthermore, political rhetoric about the need for 'cultural change', without the required changes in the distribution of power, income, wealth, or in the regulatory frameworks in society, is likely to divert from necessary action.

Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity among adults

BACKGROUND

Socioeconomic inequalities in obesity and associated risk factors for obesity are widening throughout developed countries worldwide. Tackling obesity is high on the public health agenda both in the United Kingdom and internationally. However, what works in terms of interventions that are able to reduce inequalities in obesity is lacking.

METHODS/DESIGN

The review will examine public health interventions at the individual, community and societal level that might reduce inequalities in obesity among adults aged 18 years and over, in any setting and in any country. The following electronic databases will be searched: MEDLINE, EMBASE, CINAHL, PsycINFO, Social Science Citation Index, ASSIA, IBSS, Sociological Abstracts, and the NHS Economic Evaluation Database. Database searches will be supplemented with website and gray literature searches. No studies will be excluded based on language, country or publication date. Randomized and non-randomized controlled trials, prospective and retrospective cohort studies (with/without control groups) and prospective repeat cross-sectional studies (with/without control groups) that have a primary outcome that is a proxy for body fatness and have examined differential effects with regard to socioeconomic status (education, income, occupation, social class, deprivation, poverty) or where the intervention has been targeted specifically at disadvantaged groups or deprived areas will be included. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Meta-analysis and narrative synthesis will be conducted. The main analysis will examine the effects of 1) individual, 2) community and 3) societal level public health interventions on socioeconomic inequalities in adult obesity. Interventions will be characterized by their level of action and their approach to tackling inequalities. Contextual information on how such public health interventions are organized, implemented and delivered will also be examined.

DISCUSSION

The review will provide evidence, and reveal any gaps in the evidence base, of public health strategies which reduce and prevent inequalities in the prevalence of obesity in adults and provide information on the organization, implementation and delivery of such interventions.

TRIAL REGISTRATION

PROSPERO registration number: CRD42013003612.

Traveling towards disease: transportation barriers to health care access

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

Mind the gap--reaching the European target of a 2-year increase in healthy life years in the next decade

Background: The European Innovation Partnership on Active and Healthy Ageing seeks an increase of two healthy life years (HLY) at birth in the EU27 for the next 10 years. We assess the feasibility of doing so between 2010 and 2020 and the differential impact among countries by applying different scenarios to current trends in HLY. Methods: Data comprised HLY and life expectancy (LE) at birth 2004–09 from Eurostat. We estimated HLY in 2010 in each country by multiplying the Eurostat projections of LE in 2010 by the ratio HLY/LE obtained either from country and sex-specific linear regression models of HLY/LE on year (seven countries retaining same HLY question) or extrapolating the average of HLY/LE in 2008 and 2009 to 2010 (20 countries and EU27). The first scenario continued these trends with three other scenarios exploring different HLY gap reductions between 2010 and 2020. Results: The estimated gap in HLY in 2010 was 17.5 years (men) and 18.9 years (women). Assuming current trends continue, EU27 HLY increased by 1.4 years (men) and 0.9 years (women), below the European Innovation Partnership on Active and Healthy Ageing target, with the HLY gap between countries increasing to 18.3 years (men) and 19.5 years (women). To eliminate the HLY gap in 20 years, the EU27 must gain 4.4 HLY (men) and 4.8 HLY (women) in the next decade, which, for some countries, is substantially more than what the current trends suggest. Conclusion: Global targets for HLY move attention from inter-country differences and, alongside the current economic crisis, may contribute to increase health inequalities.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Development and trialling of a tool to support a systems approach to improve social determinants of health in rural and remote Australian communities: the healthy community assessment tool

INTRODUCTION

The residents of many Australian rural and remote communities do not have the essential infrastructure and services required to support healthy living conditions and community members choosing healthy lifestyle options. Improving these social determinants of health is seen to offer real opportunities to improve health among such disadvantaged populations. In this paper, we describe the development and trialling of a tool to measure, monitor and evaluate key social determinants of health at community level.

METHODS

The tool was developed and piloted through a multi-phase and iterative process that involved a series of consultations with community members and key stakeholders and trialling the tool in remote Indigenous communities in the Northern Territory of Australia.

RESULTS

The indicators were found to be robust, and by testing the tool on a number of different levels, face validity was confirmed. The scoring system was well understood and easily followed by Indigenous and non-Indigenous study participants. A facilitated small group process was found to reduce bias in scoring of indicators.

CONCLUSION

The Healthy Community Assessment Tool offers a useful vehicle and process to help those involved in planning, service provision and more generally promoting improvements in community social determinants of health. The tool offers many potential uses and benefits for those seeking to address inequities in the social determinants of health in remote communities. Maximum benefits in using the tool are likely to be gained with cross-sector involvement and when assessments are part of a continuous quality improvement program.

Country-level economic disparity and child mortality related to housing and injuries: a study in 26 European countries

OBJECTIVE

Adverse living standards are associated with poorer child health and safety. This study investigates whether adverse housing and neighbourhood conditions contribute to explain country-level associations between a country's economic level and income inequality and child mortality, specifically injury mortality.

DESIGN

Ecological, cross-sectional study.

SETTING/SUBJECTS

Twenty-six European countries were grouped according to two country-level economic measures from Eurostat: gross domestic product (GDP) and income inequality. Adverse country-level housing and neighbourhood conditions were assessed using data from the 2006 European Union Income Social Inclusion and Living Conditions Database (n=203 000).

MAIN OUTCOME MEASURE

Child mortality incidence rates were derived for children aged 1-14 years for all causes, all injuries, road traffic injuries and unintentional injuries excluding road traffic. Linear regression analysis was applied to measure whether housing or neighbourhood conditions have a significant association with child mortality and whether a strain modified the association between GDP/income inequality and mortality.

RESULTS

Country-level income inequality and GDP demonstrated a significant association with child mortality for all outcomes. A significant association was also found between housing strain and all child mortality outcomes, but not for neighbourhood strain. Housing strain partially modified the relationship between income inequality and GDP and all child mortality outcomes, with the exception of income inequality and road traffic injury mortality showing full mediation by housing strain.

CONCLUSIONS

Adverse housing conditions are a likely pathway in the country-level association between income inequality and economic GDP and child injury mortality.

Measuring socio-economic inequalities in edentate Scottish adults--cross-sectional analyses using Scottish Health Surveys 1995-2008/09

OBJECTIVES

To investigate the appropriateness of different measures of socio-economic inequalities, in relation to adult oral health in Scotland, utilizing data from a series of large, representative population surveys.

METHODS

The Scottish Health Surveys (SHeS) (1995; 1998; 2003; 2008/09) are cross-sectional national population-based surveys used to monitor health status in those living in private households. The age groups included in this study are as follows: 45-54; 55-64 years: all survey years; 65-74: 1998 onwards; 75+: 2003 onwards. Primary outcome was no natural teeth (edentulism). Three measures of socio-economic position: Occupational social class, Education, Carstairs deprivation score (2001) were used. Simple (absolute/relative differences) and complex measures (Slope Index, Relative Index, Concentration Index and c-index) of inequality were produced for each age group across all four surveys.

RESULTS

Simple and complex (absolute) measures of inequality have both demonstrated narrowing disparities in edentulism over time in the 45- to 64-year-old group, a levelling off in those aged 65 and above, and a rise in those aged 75+. Complex relative measures (RII, Concentration Index and c-index), however, show an increasing trend in inequalities over time for all age groups, suggesting that rates of improvement in edentulism rates are not uniform across all social groups.

CONCLUSIONS

Simple absolute inequality provides a quick and easy indication of the extent of disparities between extreme groups, whereas complex measures (absolute and relative) consider the gradient in health across all social groups. We have demonstrated that both are useful measures of inequality and should be considered complementary to one another. The appropriate choice of complex measure of inequality will depend on the audience to whom the results are to be communicated. This methodological approach is not confined to oral health but is applicable to other health outcomes that are socially patterned.

Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways

Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.

Local decision makers' awareness of the social determinants of health in Turkey: a cross-sectional study

BACKGROUND

Social determinants have been described as having a greater influence than other determinants of health status. The major social determinants of health and the necessary policy objectives have been defined; it is now necessary to evaluate the effectiveness of these policies. Previous studies have shown that descriptions of the awareness level of citizens and local decision makers, practice-based research and evidence, and intersectoral studies are the best options for investigating the social determinants of health at the community level. The objective of the present study was to define local decision makers' awareness of the social determinants of health in the Aydin province of Turkey.

METHODS

A total of 53 mayors serve the Aydin city center, districts and towns. Aydin city center has 22 neighborhoods and 22 headmen responsible for them. The present study targeted all mayors and headmen in Aydin - a total of 75 possible participants. A questionnaire was used to collect the data. The questionnaire was faxed to the mayors and administered face-to-face with the headmen.

RESULTS

Headmen identified the three most important determinants of public health as environmental issues, addictions (smoking, alcohol) and malnutrition. According to the mayors, the major determinant of public health is stress, followed by malnutrition, environmental issues, an inactive lifestyle, and the social and economic conditions of the country. Both groups expressed that the Turkish Ministry of Health, municipalities and universities are the institutions responsible for developing health policy. Headmen were found to be unaware and mayors were aware of the social determinants of health as classified by the World Health Organisation. Both groups were classified as unaware with regard to their awareness of the Marmot Review policy objectives.

CONCLUSIONS

Studies such as the present study provide important additional information on the social determinants of health, and help to increase the awareness levels of both local decision-makers and the community. Such studies must be considered a vital first step in future public health research on health determinants and their impact on national and international policies.

Reducing inequality in health through evidence-based clinical guidance: is it feasible? The New Zealand experience

Evidence-based guidance and guidelines need to include the voices of the most disadvantaged groups in society; doing so is a significant challenge, but one which is critical to a responsive and healthcare system. Addressing ethnic disparity (and other types of disparity) in health via evidence-based guidance is likely to be less effective if approaches are singular and do not address issues of participation by those groups who have the greatest stake in improved health outcomes. This paper presents a multifaceted framework, which has been developed in New Zealand to ensure health inequalities experienced by Māori (the indigenous population within New Zealand) are addressed when developing evidence-based guidance. The framework has two overarching goals. These are: (i) to ensure the explicit identification of Māori health needs occurs during each formal stage of guideline development; and (ii) to ensure there is full Māori participation in the guidance development process. The steps to achieving these two goals are described in detail. The framework presented is evolving and intended to be flexible dependent upon healthcare environments and resourcing. This paper is intended to provide some focus and discussion for the role of evidence-based guidance in both addressing and entrenching health inequalities in vulnerable groups.

Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity amongst children

BACKGROUND

There is growing evidence of the impact of overweight and obesity on short- and long-term functioning, health and well-being. Internationally, childhood obesity rates continue to rise in some countries (for example, Mexico, India, China and Canada), although there is emerging evidence of a slowing of this increase or a plateauing in some age groups. In most European countries, the United States and Australia, however, socioeconomic inequalities in relation to obesity and risk factors for obesity are widening. Addressing inequalities in obesity, therefore, has a very high profile on the public health and health services agendas. However, there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity.

METHODS AND DESIGN

This article describes the protocol for a National Health Service Trust (NHS) National Institute for Health Research-funded systematic review of public health interventions at the individual, community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years. The studies will be selected only if (1) they included a primary outcome that is a proxy for body fatness and (2) examined differential effects with regard to socioeconomic status (education, income, occupation, social class, deprivation and poverty) or the intervention was targeted specifically at disadvantaged groups (for example, children of the unemployed, lone parents, low income and so on) or at people who live in deprived areas. A rigorous and inclusive international literature search will be conducted for randomised and nonrandomised controlled trials, prospective and retrospective cohort studies (with and/or without control groups) and prospective repeat cross-sectional studies (with and/or without control groups). The following electronic databases will be searched: MEDLINE, Embase, CINAHL, PsycINFO, Social Science Citation Index, ASSIA, IBSS, Sociological Abstracts and the NHS Economic Evaluation Database. Database searches will be supplemented with website and grey literature searches. No studies will be excluded on the basis of language, country of origin or publication date. Study inclusion, data extraction and quality appraisal will be conducted by two reviewers. Meta-analysis and narrative synthesis will be conducted. The main analysis will examine the effects of (1) individual, (2) community and (3) societal level public health interventions on socioeconomic inequalities in childhood obesity. Interventions will be characterised by their level of action and their approach to tackling inequalities. Contextual information on how such public health interventions are organised, implemented and delivered will also be examined.

DISCUSSION

In this review, we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity, highlight any gaps in the evidence base and seek to establish how such public health interventions are organised, implemented and delivered. PROSPERO registration number: CRD42011001740.

Multilevel analysis of income, income inequalities and health in Spain

The aim of this study is to test the influence of personal income (absolute income hypothesis), income inequalities and welfare (relative income hypothesis) on health. A multilevel cross-sectional logit model is used with two alternative specifications of the dependent variable: self-perceived health and chronic illnesses, and six specifications of the income inequality: three positive and three normative. This study incorporates lagged values of the regional variables and interactions between the individual and the regional variables. The data is drawn from the Spanish Life Conditions Survey for 2007 and consists of 28,023 individuals over 16 from 17 autonomous communities. The results support the absolute income hypothesis that a higher level of personal income is correlated with a lower probability of negative health outcomes. The relative income hypothesis results are mixed with only some indicators showing a significant relationship with health. The results also indicate that being a man, being married, working and having a high level of education are related to improved health. This study emphasizes the importance both of the health variable and of the specification of income inequality, and contributes to augmenting the limited empirical evidence available in Spain on the influence of income and income inequalities on the health of the population.

The impact of shelter use and housing placement on mortality hazard for unaccompanied adults and adults in family households entering New York City shelters: 1990-2002

This study examines mortality among New York City (NYC) homeless shelter users, assessing the relationships between mortality hazard and time in shelter, patterns of homelessness, and subsequent housing exits for both adults in families and single adults. Administrative records from the NYC shelter system were matched with death records from the Social Security Administration for 160,525 persons. Crude mortality rates and life tables were calculated, and survival analyses were undertaken using these data. Life expectancy was 64.2 and 68.6 years for single adult males and single adult females, respectively, and among adults in families, life expectancy was 67.2 and 70.1 years for males and females, respectively. For both groups, exits to stable housing (subsidized or non-subsidized) were associated with reduced mortality hazard. And while mortality hazard was substantially reduced for the time adults were in shelters, extended shelter use patterns were associated with increased mortality hazard. Differences between single homelessness and family homelessness extend to disparities in mortality rates. Although causal links cannot be established here, results suggest that, for both subgroups of the homeless population, prompt resolution of homelessness and availability of housing interventions may contribute to reduced mortality.

Prioritising public health: a qualitative study of decision making to reduce health inequalities

Background

The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.

Methods

We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.

Results

The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.

Conclusions

It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.

[Moving forward in health impact assessment: analysis of the non-health public policies of the Basque Government (Spain) as step prior to systematic screening]

Health not only depends on biologic or lifestyle factors but also on other economic, social, political, and environmental factors that shape the way people live and become ill. Thus, health policies are not the only policies affecting health, and consequently governments are increasingly interested in identifying the effect of other non-health policies on health. Health impact assessment is a prospective methodology that aims to predict the health impacts of policies before their implementation so that modifications can be suggested to maximize positive effects and avoid unexpected negative repercussions on health. The first stage in this process is screening, which can be used to select the interventions that could benefit from complete health impact assessment. Since resources are limited and not all government interventions can be assessed, tools that allow prioritization are essential. As a first stage in the validation of a systematic screening tool for health impact assessment in Spain, this article presents the process of compiling and classifying the non-health public policies of the eighth term of office of the Basque Government. Of the 97 policies analyzed, 76% were related to structural determinants of health inequalities, 79% were tactical or operational, 67% were aimed at specific population groups, and 66% were already implemented. The technical staff of other participating departments perceived the entire process of this initiative and its rationale positively. This initial experience allowed the planning of non-health policies in the Basque Country to be determined in detail as a means to move forward in incorporating impact on health in all policies.

'If no one else stands up, you have to': a story of community participation and water in rural Guatemala

BACKGROUND

Access to water is a right and a social determinant of health that should be provided by the state. However, when it comes to access to water in rural areas, the current trend is for communities to arrange for the service themselves through locally run projects. This article presents a narrative of a single community's process of participation in implementing and running a water project in the village of El Triunfo, Guatemala.

METHODS

Using an ethnographic approach, we conducted a series of interviews with five village leaders, field visits, and participant observations in different meetings and activities of the community.

FINDINGS

El Triunfo has had a long tradition of community participation, where it has been perceived as an important value. The village has a council of leaders who have worked together in various projects, although water has always been a priority. When it comes to participation, this community has achieved its goals when it collaborated with other stakeholders who provided the expertise and/or the funding needed to carry out a project. At the time of the study, the challenge was to develop a new phase of the water project with the help of other stakeholders and to maintain and sustain the tradition of participation by involving new generations in the process.

DISCUSSION

This narrative focuses on the participation in this village's efforts to implement a water project. We found that community participation has substituted the role of the central and local governments, and that the collaboration between the council and other stakeholders has provided a way for El Triunfo to satisfy some of its demand for water.

CONCLUSION

El Triunfo's case shows that for a participatory scheme to be successful it needs prolonged engagement, continued support, and successful experiences that can help to provide the kind of stable participatory practices that involves community members in a process of empowered decision-making and policy implementation.

Socioeconomic position, gender, and inequalities in self-rated health between Roma and non-Roma in Serbia

OBJECTIVE

Roma experience high levels of discrimination and social exclusion. Our objective was to examine differences in self-rated health (SRH) between Roma and non-Roma in Serbia.

METHODS

Using data from the 2007 Living Standards Measurement Survey in Serbia (n = 14,313), we used binomial regression to estimate the relative risk (RR) of poor (SRH) among Roma (n = 267) relative to non-Roma. We additionally conducted group comparisons of combinations of Romani ethnicity, poverty, and gender, relative to the baseline group of non-Roma males not in poverty.

RESULTS

Adjusting for age, Roma were more than twice as likely as non-Roma to report poor SRH (RR = 2.3, 95% Confidence Interval (CI) = 1.8, 2.8). After adjustment for household consumption, employment, and education, the RR was reduced to 1.6 (95% CI = 1.3, 2.0). Romani women, regardless of whether they were living in poverty or not, experienced the greatest risk of poor SRH, with risks relative to non-Roma males not in poverty of 3.2 (95% CI = 2.3, 4.2) and 3.1 (95% CI = 2.4, 4.0), respectively.

CONCLUSION

Roma in Serbia are at increased risk of poor SRH; Romani women experience the greatest burden of poor SRH.

Interventions for cardiovascular disease prevention

Cardiovascular disease prevention is a continuum that encompasses the life-course. This article discusses preventive strategies focusing on policy and clinical initiatives including primordial prevention (lifestyle changes involving smoking, diet and exercise), primary prevention (risk factor control), and secondary prevention (acute and chronic disease management). Combined use of all the three strategies can have an immediate and large impact on reducing CVD morbidity and mortality.

Structural interventions for HIV prevention in the United States

BACKGROUND

Structural interventions change the environment in which people act to influence their health behaviors. Most structural interventions research for HIV infection has focused on developing countries, with the United States receiving substantially less attention. This article identifies some social determinants of HIV vulnerability in the United States and structural interventions to address them.

METHODS

Review of the medical, public health, and social science literature.

RESULTS

Evidence supports widespread implementation of a number of structural interventions in the United States clearly proximate to HIV, including comprehensive sex education, universal condom availability, expanded syringe access for drug users, health care coverage, and stable housing. Sociological plausibility supports evaluation and implementation of other interventions that target social determinants more distal but of relevance to HIV, such as initiatives to eliminate racial and ethnic disparities in criminal sentencing, to promote early childhood education and to decrease poverty.

CONCLUSIONS

Structural interventions that address social determinants of HIV infection may be among the most cost effective methods of preventing HIV infection in the United States over the long term.

The socioeconomic determinants of cancer

This paper provides a synthesis on socioeconomic inequalities in cancer incidence, mortality and survival across countries and within countries, with particular focus on the Italian context; the paper also describes the underlying mechanisms documented for cancer incidence, and reports some remarks on policies to tackle inequalities.From a worldwide perspective, the burden of cancer appears to be particularly increasing in developing countries, where many cancers with a poor prognosis (liver, stomach and oesophagus) are much more common than in richer countries. As in the case of incidence and mortality, also in cancer survival we observe a great variability across countries. Different studies have suggested a possible impact of health care on the social gradients in cancer survival, even in countries with a National Health System providing equitable access to care.In developed countries, there is increasing awareness of social inequalities as an important public health issue; as a consequence, there is a variety of strategies and policies being implemented throughout Europe. However, recent reviews emphasize that present knowledge on effectiveness of policies and interventions on health inequalities is not sufficient to offer a robust and evidence-based guide to the choice and design of interventions, and that more evaluation studies are needed.The large disparities in health that we can measure within and between countries represent a challenge to the world; social health inequalities are avoidable, and their reduction therefore represents an achievable goal and an ethical imperative.

The social determinants of tuberculosis: from evidence to action

Growing consensus indicates that progress in tuberculosis control in the low- and middle-income world will require not only investment in strengthening tuberculosis control programs, diagnostics, and treatment but also action on the social determinants of tuberculosis. However, practical ideas for action are scarcer than is notional support for this idea. We developed a framework based on the recent World Health Organization Commission on Social Determinants of Health and on current understanding of the social determinants of tuberculosis. Interventions from outside the health sector-specifically, in social protection and urban planning-have the potential to strengthen tuberculosis control.

Translating evidence into policy for cardiovascular disease control in India

Cardiovascular diseases (CVD) are leading causes of premature mortality in India. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors-smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity has now achieved international political importance with endorsement from the World Health Assembly in 2009.  The failure of systematic reviews to consider effects on health equity is cited by decision-makers as a limitation to their ability to inform policy and program decisions. 

OBJECTIVES

To systematically review methods to assess effects on health equity in systematic reviews of effectiveness.

SEARCH STRATEGY

We searched the following databases up to July 2 2010: MEDLINE, PsychINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Index to Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on October 7 2010.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities.

DATA COLLECTION AND ANALYSIS

Data were extracted using a pre-tested form by two independent reviewers. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews. 

MAIN RESULTS

Thirty-four methodological studies were included.  The methods used by these included studies were: 1) Targeted approaches (n=22); 2) gap approaches (n=12) and gradient approach (n=1).  Gender or sex was assessed in eight out of 34 studies, socioeconomic status in ten studies, race/ethnicity in seven studies, age in seven studies, low and middle income countries in 14 studies, and two studies assessed multiple factors across health inequity may exist.Only three studies provided a definition of health equity. Four methodological approaches to assessing effects on health equity were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (all 34 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (12/34 studies); 3) analytic approaches (10/34 studies); and 4) applicability assessment (11/34 studies). Both analytic and applicability approaches were not reported transparently nor in sufficient detail to judge their credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to assess and report effects on health equity in systematic reviews.

[Social inequalities in child health. SESPAS report 2010]

There is considerable evidence of the impact of poverty and social exclusion on child health. In the last few years, interest has grown in the concept of social gradients in health, according to social position, family educational level, gender, and ethnic background. Several cohort studies have demonstrated an association between maternal socioeconomic position during the prenatal period and adult health. The Commission on Social Determinants of Health of the World Health Organization proposed closing the health gap in a generation by giving a major role to early child development. Family educational level and academic achievement are fundamental determinants of health inequalities. There is scarce empirical evidence on the effectiveness of interventions to reduce child health inequalities. Most of the interventions in children and adolescents aim to change individual behavior, and very few have been critically evaluated. The present manuscript provides a review of initiatives and recent interventions aimed at reducing social inequalities, as well as a checklist to be taken into account in interventions on health promotion and disease prevention in schools from the perspective of social and gender inequalities. Strategies for data collection, research and health and educational policies are proposed.

Housing and health inequalities: a synthesis of systematic reviews of interventions aimed at different pathways linking housing and health

Housing and neighbourhood conditions are widely acknowledged to be important social determinants of health, through three main pathways: (1) internal housing conditions, (2) area characteristics and (3) housing tenure. We conducted a systematic overview of systematic reviews of intervention studies to provide an overview of the evidence on the impact of housing and neighbourhood interventions on health and health inequalities. There is relatively strong evidence for interventions aimed at improving area characteristics and compelling evidence for warmth and energy efficiency interventions targeted at vulnerable individuals. However, the health impacts of area-level internal housing improvement interventions are as yet unclear. We found no reviews of interventions aimed at altering housing tenure. This remains an important area for further research and potentially new evidence syntheses.

[Research on social determinants of health and health inequalities: evidence for health in all policies]

This article aims to review conceptual frameworks and some principles to be considered in research on social determinants of health and health inequalities. Some indicators of research on these issues in Spain are described. General expenditure on research and development in Spain is far from the Organisation for Economic Co-operation and Development mean. In addition, both globally and within Spain, the scientific production on health inequalities is very low, especially compared with other research areas. The budget for research on health inequalities is also reduced. A striking example is provided by analysis of the projects funded by the Marató de TV3, which seems to have little interest in funding research on health inequalities. However, both the scientific production and project financing on health inequalities have increased in the last decade. Finally, to advance research on health inequalities and its contribution to the incorporation of health in all policies, recommendations are made, which include redefining priorities, ensuring resources and promoting knowledge translation.

Challenges in evaluating Welfare to Work policy interventions: would an RCT design have been the answer to all our problems?

Background

UK policy direction for recipients of unemployment and sickness benefits is to support these people into employment by increasing 'into work' interventions. Although the main aim of associated interventions is to increase levels of employment, improved health is stated as a benefit, and a driver of these interventions. This is therefore a potentially important policy intervention with respect to health and health inequalities, and needs to be validated through rigorous impact evaluation.

We attempted to evaluate the Pathways Advisory Service intervention which aims to provide employment support for Incapacity Benefit recipients, but encountered a number of challenges and barriers to evaluation. This paper explores the issues that arose in designing a suitable evaluation of the Pathways Advisory Service.

Discussion

The main issues that arose were that characteristics of the intervention lead to difficulties in defining a suitable comparison group; and governance restrictions such as uncertainty regarding ethical consent processes and data sharing between agencies for research. Some of these challenges threatened fundamentally to limit the validity of any experimental or quasi-experimental evaluation we could design - restricting recruitment, data collection and identification of an appropriate comparison group. Although a cluster randomised controlled trial design was ethically justified to evaluate the Pathways Advisory Service, this was not possible because the intervention was already being widely implemented. However, this would not have solved other barriers to evaluation. There is no obvious method to perform a controlled evaluation for interventions where only a small proportion of those eligible are exposed. Improved communication between policymakers and researchers, clarification of data sharing protocols and improved guidelines for ethics committees are tangible ways which may reduce the current obstacles to this and other similar evaluations of policy interventions which tackle key determinants of health.

Summary

The evaluation of social interventions is hampered by more than their suitability to randomisation. Data sharing, participant identification and recruitment problems are common to randomised and non-randomised evaluation designs. These issues require further attention if we are to learn from current social policy.

Reducing health inequalities in priority public health conditions: using rapid review to develop proposals for evidence-based policy

BACKGROUND

In November 2008, the Secretary of State for Health (England) commissioned an independent review to propose effective strategies for reducing health inequalities. Review task groups were given just 3 months to make preliminary evidence-based recommendations. In this paper, we describe the methodology used, and the recommendations made, by the group tasked with inequalities in priority public health conditions.

METHODS

A series of rapid literature reviews of the policy-relevant international evidence base was undertaken. Quantitative studies of any design, which looked at the effects on health inequalities, the social gradient or overall population health effects, of interventions designed to address the social determinants of selected public health priority conditions were examined. Recommendations were distilled using a Delphi approach.

RESULTS

Five key policy proposals were made: reduce smoking in the most deprived groups; improve availability of and access to healthier food choices amongst low income groups; improve the early detection and treatment of diseases; introduce a minimum price per unit for alcohol and improve the links between physical and mental health care.

CONCLUSION

The combination of rapid review and Delphi distillation produced a shortlist of evidence-based recommendations within the allocated time frame. There was a dearth of robust evidence on the effectiveness and cost-effectiveness of the interventions we examined: our proposals had to be based on extrapolation from general population health effects. Extensive, specific and robust evidence is urgently needed to guide policy and programmes. In the meantime, our methodology provides a reasonably sound and pragmatic basis for evidence-based policy-making.

Flexible working conditions and their effects on employee health and wellbeing

BACKGROUND

Flexible working conditions are increasingly popular in developed countries but the effects on employee health and wellbeing are largely unknown.

OBJECTIVES

To evaluate the effects (benefits and harms) of flexible working interventions on the physical, mental and general health and wellbeing of employees and their families.

SEARCH STRATEGY

Our searches (July 2009) covered 12 databases including the Cochrane Public Health Group Specialised Register, CENTRAL; MEDLINE; EMBASE; CINAHL; PsycINFO; Social Science Citation Index; ASSIA; IBSS; Sociological Abstracts; and ABI/Inform. We also searched relevant websites, handsearched key journals, searched bibliographies and contacted study authors and key experts.

SELECTION CRITERIA

Randomised controlled trials (RCT), interrupted time series and controlled before and after studies (CBA), which examined the effects of flexible working interventions on employee health and wellbeing. We excluded studies assessing outcomes for less than six months and extracted outcomes relating to physical, mental and general health/ill health measured using a validated instrument. We also extracted secondary outcomes (including sickness absence, health service usage, behavioural changes, accidents, work-life balance, quality of life, health and wellbeing of children, family members and co-workers) if reported alongside at least one primary outcome.

DATA COLLECTION AND ANALYSIS

Two experienced review authors conducted data extraction and quality appraisal. We undertook a narrative synthesis as there was substantial heterogeneity between studies.

MAIN RESULTS

Ten studies fulfilled the inclusion criteria. Six CBA studies reported on interventions relating to temporal flexibility: self-scheduling of shift work (n = 4), flexitime (n = 1) and overtime (n = 1). The remaining four CBA studies evaluated a form of contractual flexibility: partial/gradual retirement (n = 2), involuntary part-time work (n = 1) and fixed-term contract (n = 1). The studies retrieved had a number of methodological limitations including short follow-up periods, risk of selection bias and reliance on largely self-reported outcome data. Four CBA studies on self-scheduling of shifts and one CBA study on gradual/partial retirement reported statistically significant improvements in either primary outcomes (including systolic blood pressure and heart rate; tiredness; mental health, sleep duration, sleep quality and alertness; self-rated health status) or secondary health outcomes (co-workers social support and sense of community) and no ill health effects were reported. Flexitime was shown not to have significant effects on self-reported physiological and psychological health outcomes. Similarly, when comparing individuals working overtime with those who did not the odds of ill health effects were not significantly higher in the intervention group at follow up. The effects of contractual flexibility on self-reported health (with the exception of gradual/partial retirement, which when controlled by employees improved health outcomes) were either equivocal or negative. No studies differentiated results by socio-economic status, although one study did compare findings by gender but found no differential effect on self-reported health outcomes.

AUTHORS' CONCLUSIONS

The findings of this review tentatively suggest that flexible working interventions that increase worker control and choice (such as self-scheduling or gradual/partial retirement) are likely to have a positive effect on health outcomes. In contrast, interventions that were motivated or dictated by organisational interests, such as fixed-term contract and involuntary part-time employment, found equivocal or negative health effects. Given the partial and methodologically limited evidence base these findings should be interpreted with caution. Moreover, there is a clear need for well-designed intervention studies to delineate the impact of flexible working conditions on health, wellbeing and health inequalities.