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

Social Needs Screening in Academic Health Systems: A Landscape Assessment

Screening for social needs has gained traction as an approach to addressing social determinants of health, but it faces challenges regarding standardization, resource allocation, and follow-up care. The year-long study, conducted by the Association of American Medical Colleges, integrated data from conferences, surveys, and key informant interviews to examine the integration of social needs screening into health care services within Academic Health Systems (AHS). The authors' analysis unveiled eight key themes, showcasing AHS's active involvement in targeted social needs screening alongside persistent resource allocation obstacles. AHS are dedicated to efficiently identifying high-risk populations, fostering partnerships with community-based organizations, and embracing technology for closed-loop referrals. However, concerns endure about the utilization of reimbursement codes for social needs and regulatory compliance. AHS confront staffing issues, resource allocation intricacies, and the imperative for seamless integration across clinical and nonclinical departments. Notably, opportunities arise in standardized training, alignment of AHS priorities, exploration of social investment models, and engagement with state-level health information exchanges. Aligning clinical care, research pursuits, and community engagement endeavors holds promise for AHS in effectively addressing social needs.

Health behavior interventions among people with lower socio-economic position: a scoping review of behavior change techniques and effectiveness

Background

Behavior change interventions can unintendedly widen existing socio-economic health inequalities. Understanding why interventions are (in)effective among people with lower socio-economic position (SEP) is essential. Therefore, this scoping review aims to describe what is reported about the behavior change techniques (BCTs) applied within interventions and their effectiveness in encouraging physical activity and healthy eating, and reducing smoking and alcohol consumption according to SEP.

Methods

A systematic search was conducted in 12 electronic databases, and 151 studies meeting the eligibility criteria were included and coded for health behavioral outcomes, SEP-operationalization, BCTs (type and number) and effectiveness.

Results

Findings suggest that approaches for measuring, defining and substantiating lower SEP vary. Current studies of behavior change interventions for people of different SEP do not systematically identify BCTs, making systematic evaluation of BCT effectiveness impossible. The effectiveness of interventions is mainly evaluated by overall intervention outcomes and SEP-moderation effects are mostly not assessed.

Conclusion

Using different SEP-operationalizations and not specifying BCTs hampers systematic evidence accumulation regarding effective (combinations of) BCTs for the low SEP population. To learn which BCTs effectively improve health behaviors among people with lower SEP, future intervention developers should justify how SEP is operationalized and must systematically describe and examine BCTs.

Does better than expected life expectancy in areas of disadvantage indicate health resilience? Stakeholder perspectives and possible explanations

Some places have better than expected health trends despite being disadvantaged in other ways. Thematic analysis of qualitative data from stakeholders (N = 25) in two case studies of disadvantaged local authorities the North West and South East of England assessed explanations for the localities' apparent health resilience. Participants identified ways of working that might contribute to improved life expectancy, such as partnering with third sector, targeting and outcome driven action. Stakeholders were reluctant to assume credit for better-than-expected health outcomes. External factors such as population change, national politics and finances were considered crucial. Local public health stakeholders regard their work as important but unlikely to cause place-centred health resilience.

A global survey of national oral health policies and its coverage for young children

Background

There is no accessible information on countries with oral health policies. The purpose of this study was to identify World Dental Federation (FDI) member countries with oral health policies and their scope and extent of coverage of oral health care for young children.

Methods

This international survey recruited chief dental officers, oral health advisors to national ministries of health, and other key informants of the 158 FDI member countries between December 2020 and December 2021. The survey tool was administered online to the study participants. Key questions explored the following outcome measures: countries with oral health policies; the thrusts of the oral health policies; policy thrusts targeting young children; and dental care plans as a component of a universal health care plan. Descriptive statistics were conducted to determine the number of countries with any of the study outcome measures and coverage per country.

Results

Sixty (38%) of the 158 FDI member-countries responded to the survey. Forty-eight (55.2%) of the 60 countries had a national oral health policy document or position statement on oral health; 54 (62.1%) countries had plans on universal health care, and 42 (48.3%) included dental care within their universal health care plan. The most common policy thrusts addressing the oral health needs of children were the promotion of oral hygiene (71.7%), provision of fluoride products for children (53.3%), collaboration with primary care providers (35%), and prenatal oral health education (50%). There were differences in the scope of oral health care coverage and the coverage for young children between continents as well as between countries. Europe had many countries with children-friendly oral health policy coverage.

Conclusions

About half of the surveyed countries had a national oral health policy. There were variations in the scope of oral health care coverage, particularly for young children, both between continents and among individual countries. These findings underscore the importance of understanding the landscape of oral health policies globally. Such insights can help inform targeted interventions to enhance oral health policies, thereby contributing to improved oral health outcomes on a global level.

Education and medication use later in life and the role of intelligence

We investigate the association between education and disease-specific medications in old age, prescribed by medical doctors, accounting for confounders and how this association is shaped by intelligence. We use administrative data on men including prescribed medication records. To account for endogeneity of education we estimate a structural model, consisting of (i) an ordered probit for educational attainment, (ii) a Gompertz mortality model for survival up to old age, (iii) a probit model for prescribed medications in old age, (iv) a measurement system using IQ tests to identify latent intelligence. The results suggest a strong effect of education on prescribed medications for most medications, except for prescribed medication for cardiac diseases and for depression and anxiety.

Pressurizing or encouraging: Health behaviors among long-distance couples

Couples in long-distance relationships face unique challenges that affect their health outcomes and relationship dynamics in ways that are different from couples in close proximal relationships (PR). The results of previous literature analyzing health outcomes for long-distance relationship (LDR) couples have been mixed, and factors such as couple satisfaction and gender of the individuals contribute to the variance. This study examined the good health practices of couples in LDRs, the ways in which partners influence each other's health, and the health outcomes of these couples as compared to couples in PRs. Multilevel multivariate analysis showed that couples in LDRs had better health practices than those in PRs, and men overall had poorer health practices than women. There was no main effect seen for LDRs when we examined strategies used for influencing health. There was a main effect for gender, though, and we found that women tend to use more collaborative and pressurizing strategies for influencing their partner's health. On health indices, we found that LDR couples tended to have lower levels of fatigue and sleep disturbance as compared to PR couples. In the adjusted model with covariates, which included age, income, couple satisfaction, and married or unmarried couples, we found that lower couple satisfaction and lower income significantly predicted poorer health on all health indices. These results are discussed in light of unequal gender roles, social control, and positive aspects of LDRs on health in an attempt to understand LDRs better and destigmatize the narrative of these relationships as 'less than' PRs. Implications for health and mental health practitioners are also discussed.

Regional socioeconomic deprivation in Germany and nicotine use among children and adolescents

To assess the association of regional socioeconomic deprivation and nicotine use, survey data from 17,877 pupils aged 9-17 years were analysed. Lifetime use of combustible, e-cigarettes, and both products were the outcome variables. The German Index of Socioeconomic Deprivation was the exposure variable. Logistic regression models controlling for age, gender, school type, and sensation seeking were used to examine associations between regional socioeconomic deprivation and nicotine use. Ever use of combustible cigarettes was 17.8%, of e-cigarettes 19.6%, and of both products 13.4%. Compared to the most affluent area, the adjusted odds ratio of combustible cigarette use in the most deprived area was 2.24 (95% CI: 1.67-3.00), of e-cigarette use 1.56 (95% CI: 1.20-2.03), and of poly use 1.91 (95% CI: 1.36-2.69). Nicotine use among young people across ages and especially in socioeconomic-deprived areas was widespread. Nicotine control measures are urgently needed to reduce smoking and vaping in German adolescents.

The link between involuntary non-regular employment and poor mental health: A cross-sectional study of Japanese workers

Involuntary non-regular employment is a severe inequity problem worldwide, and it may significantly affect the mental health of employees. The present study aimed to examine the relationship between employment type and mental health. Additionally, the characteristics of involuntary non-regularly employed workers were explored. An online-based cross-sectional study was conducted in Japan, and 1566 participants were included in the data analysis. The eligible participants were divided into four categories: regularly employed (n = 1092), voluntary (n = 134), average (n = 233) and involuntary (n = 107) non-regularly employed individuals, respectively. Involuntary non-regular employment was associated with greater lack of vigour, anger-irritability, fatigue, anxiety, and depression. It was higher among women, those who were single or had no childcare, and those who had lower personal income or shorter working hours, or who tended not to practice relaxation activities. Lower personal income was associated with a risk of anxiety and depressive symptoms. Those individuals experiencing involuntary non-regular employment had a higher risk of poor mental health; subgroup analysis showed that this was particularly true among men. Both encouragement of employment stability via policy reform and workplace mental health support for involuntary non-regularly employed individuals are urgent health concerns.

A contemporary class structure: Capital disparities in The Netherlands

The academic and public debate on social inequality has recently been fuelled by large disparities in income and wealth, profound changes in the labour market, and other emerging cleavages in post-industrial societies. This article contributes to the discussion by arguing that class divisions are theoretically based on four types of capital: people's economic means, their social capital, their cultural resources, and the combination of their health and attractiveness ('person capital'). From this premise, the social structure of the Netherlands is examined. A dedicated survey was linked to microdata from the national population register, tax authorities and benefit agencies. Using latent class analysis, we assess contingencies in the distribution of the different resources, and identify a structure consisting of six capital groups. The established upper echelon (15.5% of the adult population) has the most capital, followed by the privileged younger people (12.7%), the employed middle echelon (26.9%) and the comfortable retirees (16.6%). Total capital is lowest among the insecure workers (13.5%) and the precariat (14.8%). Each social class has a distinctive mix of the four types of capital, highlighting the need to look beyond economic differences in order to comprehend structural inequality. The results of this study also indicate that resource disparities between classes coincide with other forms of social hierarchy and contrasts by age. Moreover, the contemporary class structure is associated with divergent views and experiences among the Dutch. Classes with little capital tend to rate politics, society, and their own social position more negatively. In addition, they value self-enhancement and hedonism less than today's upper classes and report lower levels of well-being.

Empathy as a crucial skill in disrupting disparities in global brain health

Brain health refers to the state of a person's brain function across various domains, including cognitive, behavioral and motor functions. Healthy brains are associated with better individual health, increased creativity, and enhanced productivity. A person's brain health is intricately connected to personal, social and environmental factors. Racial, ethnic, and social disparities affect brain health and on the global scale these disparities within and between regions present a hurdle to brain health. To overcome global disparities, greater collaboration between practitioners and healthcare providers and the people they serve is essential. This requires cultural humility driven by empathy. Empathy is a core prosocial value, a cognitive-emotional skill that helps us understand ourselves and others. This position paper aims to provide an overview of the vital roles of empathy, cooperation, and interdisciplinary partnerships. By consciously integrating this understanding in practice, leaders can better position themselves to address the diverse challenges faced by communities, promote inclusivity in policies and practices, and further more equitable solutions to the problem of global brain health.

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action

INTRODUCTION

It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.

METHODS

Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.

FINDINGS

Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.

CONCLUSION

Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these.

PUBLIC CONTRIBUTION

An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

Is socioeconomic inequality in antenatal care coverage widening or reducing between- and within-socioeconomic groups? A case of 19 countries in sub-Saharan Africa

Maternal health statistics have improved in many countries in sub-Saharan Africa (SSA). Still, progress remains slow in meeting the Sustainable Development Goals (SDG) targets. Accelerating antenatal care (ANC) coverage is critical to improving maternal health outcomes. To progress, countries should understand whether to target reducing health disparities between- or within-socioeconomic groups, as policies for achieving these may differ. This paper develops a framework for decomposing changes in socioeconomic inequalities in health into changes in between- and within-socioeconomic groups using the concentration index, a popular measure for assessing socioeconomic inequalities in health. It begins by noting the challenge in decomposing the concentration index into only between- and within-group components due to the possibility of an overlap created by overlapping distributions of socioeconomic status between groups. Using quantiles of socioeconomic status provides a convenient way to decompose the concentration index so that the overlap component disappears. In characterising the decomposition, a pro-poor shift occurs when socioeconomic inequality is reduced over time, including between- and within-socioeconomic groups, while a pro-rich shift or change occurs conversely. The framework is applied to data from two rounds of the Demographic and Health Survey of 19 countries in SSA conducted about ten years apart in each country. It assessed changes in socioeconomic inequalities in an indicator of at least four antenatal care visits (ANC4+) and the count of ANC visits (ANC intensity). The results show that many countries in SSA witnessed significant pro-poor shifts or reductions in socioeconomic inequalities in ANC coverage because pro-rich inequalities in ANC4+ and ANC intensity become less pro-rich. Changes in between-socioeconomic group inequalities drive the changes in ANC service coverage inequalities in all countries. Thus, policies addressing inequalities between-socioeconomic groups are vital to reducing overall disparities and closing the gap between the rich and the poor, a crucial objective for the SDGs.

Income inequality and pandemics: insights from HIV/AIDS and COVID-19-a multicountry observational study

OBJECTIVES

Assess the relationship between income inequality and HIV incidence, AIDS mortality and COVID-19 mortality.

DESIGN

Multicountry observational study.

SETTING

217 countries for HIV/AIDS analysis, 151 countries for COVID-19 analysis.

PARTICIPANTS

Used three samples of national-level data: a sample of all countries with available data (global sample), a subsample of African countries (African sample) and a subsample excluding African countries (excluding African sample).

MAIN OUTCOME MEASURES

HIV incidence rate per 1000 people, AIDS mortality rate per 100 000 people and COVID-19 excess mortality rate per 100 000 people. The Gini index of income inequality was the primary explanatory variable.

RESULTS

A positive and significant relationship exists between the Gini index of income inequality and HIV incidence across all three samples (p<0.01), with the effect of income inequality on HIV incidence being higher in the African sample than in the rest of the world. Also, a statistically positive association exists for all samples between income inequality and the AIDS mortality rate, as higher income inequality increases AIDS mortality (p<0.01). For COVID-19 excess mortality rate, a positive and statistically significant relationship exists with the Gini index for the entire sample and the excluding African sample (p<0.05), but the African sample alone did not deliver significant results (p<0.1).

CONCLUSION

COVID-19 excess deaths, HIV incidence and AIDS mortality are significantly associated with income inequality globally-more unequal countries have a higher HIV incidence, AIDS mortality and COVID-19 excess deaths than their more equal counterparts. Income inequality undercuts effective pandemic response. There is an urgent need for concerted efforts to tackle income inequality and to build pandemic preparedness and responses that are adapted and responsive to highly unequal societies, prioritising income inequality among other social determinants of health.

US State Policy Contexts and Population Health

Policy Points This Perspective connects the dots between the polarization in US states' policy contexts and the divergence in population health across states. Key interlocking forces that fueled this polarization are the political investments of wealthy individuals and organizations and the nationalization of US political parties. Key policy priorities for the next decade include ensuring all Americans have opportunities for economic security, deterring behaviors that kill or injure hundreds of thousands of Americans each year, and protecting voting rights and democratic functioning.

How well do area-based deprivation indices identify income- and employment-deprived individuals across Great Britain today?

BACKGROUND

Area-based deprivation indices are used in many countries to target interventions and policies to populations with the greatest needs. Analyses of the Carstairs deprivation index applied to postcode sectors in 2001 identified that less than half of all deprived individuals lived in the most deprived areas.

OBJECTIVE

This article examines the specificity and sensitivity of deprivation indices across Great Britain in identifying individuals claiming income- and employment-related social security benefits.

STUDY DESIGN

This was a descriptive analysis of cross-sectional administrative data.

METHODS

The data sets for the 2020 Scottish Index of Multiple Deprivation, Scottish Income and Employment Index, the 2019 English Index of Multiple Deprivation and the 2019 Welsh Index of Multiple Deprivation were obtained. For each data set, small areas were ranked by increasing overall deprivation, and the cumulative proportions of individuals who were income and employment deprived were calculated. Receiver operating characteristic curves were plotted to show the sensitivity and specificity of each index, and the percentages of income- and employment-deprived individuals captured at different overall deprivation thresholds were calculated.

RESULTS

Across all indices, the sensitivity and specificity for detecting income- and employment-deprived individuals were low, with less than half living in the most deprived 20% of areas. Between 55% and 62% of income-deprived people and between 56% and 63% of employment-deprived people were missed across the indices at the 20% deprivation threshold. The sensitivity and specificity were slightly higher for income deprivation than employment deprivation across indices and slightly higher for the Scottish Index of Multiple Deprivation and Scottish Income and Employment Index than for the English Index of Multiple Deprivation and Welsh Index of Multiple Deprivation.

CONCLUSION

Area-based deprivation measures in Great Britain have limited sensitivity and specificity for identifying individuals who are income or employment deprived. Place-based policies and interventions are unlikely to be effective at reducing inequalities as a result. Creation of individually linked data sets and interventions that recognise the social and economic relationships between social groups are likely to be more effective.

Governance of Intersectoral Collaborations for Population Health and to Reduce Health Inequalities in High-Income Countries: A Complexity-Informed Systematic Review

BACKGROUND

A 'Health in All Policies' (HiAP) approach has been widely advocated as a way to involve multiple government sectors in addressing health inequalities, but implementation attempts have not always produced the expected results. Explaining how HiAP-style collaborations have been governed may offer insights into how to improve population health and reduce health inequalities.

METHODS

Theoretically focused systematic review. Synthesis of evidence from evaluative studies into a causal logic model.

RESULTS

Thirty-one publications based on 40 case studies from nine high-income countries were included. Intersectoral collaborations for population health and equity were multi-component and multi-dimensional with collaborative activity spanning policy, strategy, service design and service delivery. Governance of intersectoral collaboration included structural and relational components. Both internal and external legitimacy and credibility delivered collaborative power, which in turn enabled intersectoral collaboration. Internal legitimacy was driven by multiple structural elements and processes. Many of these were instrumental in developing (often-fragile) relational trust. Internal credibility was supported by multi-level collaborations that were adequately resourced and shared power. External legitimacy and credibility was created through meaningful community engagement, leadership that championed collaborations and the identification of 'win-win' strategies. External factors such as economic shocks and short political cycles reduced collaborative power.

CONCLUSION

This novel review, using systems thinking and causal loop representations, offers insights into how collaborations can generate internal and external legitimacy and credibility. This offers promise for future collaborative activity for population health and equity; it presents a clearer picture of what structural and relational components and dynamics collaborative partners can focus on when planning and implementing HiAP initiatives. The limits of the literature base, however, does not make it possible to identify if or how this might deliver improved population health or health equity.

Agent-Based Modelling of Health Inequalities following the Complexity Turn in Public Health: A Systematic Review

There is an increasing focus on the role of complexity in public health and public policy fields which has brought about a methodological shift towards computational approaches. This includes agent-based modelling (ABM), a method used to simulate individuals, their behaviour and interactions with each other, and their social and physical environment. This paper aims to systematically review the use of ABM to simulate the generation or persistence of health inequalities. PubMed, Scopus, and Web of Science (1 January 2013-15 November 2022) were searched, supplemented with manual reference list searching. Twenty studies were included; fourteen of them described models of health behaviours, most commonly relating to diet (n = 7). Six models explored health outcomes, e.g., morbidity, mortality, and depression. All of the included models involved heterogeneous agents and were dynamic, with agents making decisions, growing older, and/or becoming exposed to different health risks. Eighteen models represented physical space and in eleven models, agents interacted with other agents through social networks. ABM is increasingly contributing to our understanding of the socioeconomic inequalities in health. However, to date, the majority of these models focus on the differences in health behaviours. Future research should attempt to investigate the social and economic drivers of health inequalities using ABM.

Desperately Seeking Intersectionality in Digital Health Disparity Research: Narrative Review to Inform a Richer Theorization of Multiple Disadvantage

BACKGROUND

Digital consultations between patients and clinicians increased markedly during the COVID-19 pandemic, raising questions about equity.

OBJECTIVE

This study aimed to review the literature on how multiple disadvantage-specifically, older age, lower socioeconomic status, and limited English proficiency-has been conceptualized, theorized, and studied empirically in relation to digital consultations. We focused mainly on video consultations as they have wider disparities than telephone consultations and relevant data on e-consultations are sparse.

METHODS

Using keyword and snowball searching, we identified relevant papers published between 2012 and 2022 using Ovid MEDLINE, Web of Science, Google Scholar, and PubMed. The first search was completed in July 2022. Papers meeting the inclusion criteria were analyzed thematically and summarized, and their key findings were tabulated using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research criteria. Explanations for digital disparities were critically examined, and a search was undertaken in October 2022 to identify theoretical lenses on multiple disadvantage.

RESULTS

Of 663 articles from the initial search, 27 (4.1%) met our inclusion criteria. In total, 37% (10/27) were commentaries, and 63% (17/27) were peer-reviewed empirical studies (11/27, 41% quantitative; 5/27, 19% qualitative; 1/27, 4% mixed methods; 1/27, 4% systematic reviews; and 1/27, 4% narrative reviews). Empirical studies were mostly small, rapidly conducted, and briefly reported. Most studies (25/27, 93%) identified marked digital disparities but lacked a strong theoretical lens. Proposed solutions focused on identifying and removing barriers, but the authors generally overlooked the pervasive impact of multiple layers of disadvantage. The data set included no theoretically informed studies that examined how different dimensions of disadvantage combined to affect digital health disparities. In our subsequent search, we identified 3 theoretical approaches that might help account for these digital disparities. Fundamental cause theory by Link and Phelan addresses why the association between socioeconomic status and health is pervasive and persists over time. Digital capital theory by Ragnedda and Ruiu explains how people mobilize resources to participate in digitally mediated activities and services. Intersectionality theory by Crenshaw states that systems of oppression are inherently bound together, creating singular social experiences for people who bear the force of multiple adverse social structures.

CONCLUSIONS

A limitation of our initial sample was the sparse and undertheorized nature of the primary literature. The lack of attention to how digital health disparities emerge and play out both within and across categories of disadvantage means that solutions proposed to date may be oversimplistic and insufficient. Theories of multiple disadvantage have bearing on digital health, and there may be others of relevance besides those discussed in this paper. We call for greater interdisciplinary dialogue between theoretical research on multiple disadvantage and empirical studies on digital health disparities.

Trends in inequality in maternal and child health and health care in Uganda: Analysis of the Uganda demographic and health surveys

BACKGROUND

Uganda has made great strides in improving maternal and child health. However, little is known about how this improvement has been distributed across different socioeconomic categories, and how the health inequalities have changed over time. This study analyses data from Demographic and Health Surveys (DHS) conducted in 2006, 2011, and 2016 in Uganda, to assess trends in inequality for a variety of mother and child health and health care indicators.

METHODS

The indicators studied are acknowledged as critical for monitoring and evaluating maternal and child health status. These include infant and child mortality, underweight status, stunting, and prevalence of diarrhea. Antenatal care, skilled birth attendance, delivery in health facilities, contraception prevalence, full immunization coverage, and medical treatment for child diarrhea and Acute Respiratory tract infections (ARI) are all health care indicators. Two metrics of inequity were used: the quintile ratio, which evaluates discrepancies between the wealthiest and poorest quintiles, and the concentration index, which utilizes data from all five quintiles.

RESULTS

The study found extraordinary, universal improvement in population averages in most of the indices, ranging from the poorest to the wealthiest groups, between rural and urban areas. However, significant socioeconomic and rural-urban disparities persist. Under-five mortality, malnutrition in children (Stunting and Underweight), the prevalence of anaemia, mothers with low Body Mass Index (BMI), and the prevalence of ARI were found to have worsening inequities. Healthcare utilization measures such as skilled birth attendants, facility delivery, contraceptive prevalence rate, child immunization, and Insecticide Treated Mosquito Net (ITN) usage were found to be significantly lowering disparity levels towards a perfect equity stance. Three healthcare utilization indicators, namely medical treatment for diarrhea, medical treatment for ARI, and medical treatment for fever, demonstrated a perfect equitable situation.

CONCLUSION

Increased use of health services among the poor and rural populations leads to improved health status and, as a result, the elimination of disparities between the poor and the wealthy, rural and urban people.

RECOMMENDATION

Intervention initiatives should prioritize the impoverished and rural communities while also considering the wealthier and urban groups.

Food Retail Network Spatial Matching and Urban Planning Policy Implications: The Case of Beijing, China

Food is the core of urban daily life and socio-economic activities but is rarely the focus of urban planning. The spatial layout of food retail outlets is important for optimizing the urban food system, improving land resource allocation, and encouraging healthy food consumption. Based on food retail POI data, this study employed kernel density estimation, road network centrality, spatial autocorrelation analysis, and locational entropy to analyze the spatial characteristics of supermarkets, produce markets, and small stores in an urban center in Beijing, and explored street coupling and supply-demand matching. The results indicated that within the study area: (1) supermarkets had an obvious “core-periphery” distribution, produce markets had a polycentric distribution, and small stores had a relatively uniform distribution; (2) road network centrality indices revealed a differentiated multi-core-edge distribution; (3) streets with high locational entropy values for supermarkets and produce markets were mostly concentrated in the central area, whereas the matching distribution of small stores was relatively balanced. From the perspective of urban planning, policy implications are proposed based on spatial and social equity, urban-rural differences, population structure and distribution status, and a resilient supply chain. The study findings have practical significance for guiding the development of urban food systems in a healthy, just, and sustainable direction, as well as rational urban land planning.

Determinant and status of income disparity among urban households

The policy message for the developing world was clear: you can’t expect to have both lower poverty and less inequality while you remain poor, and if you choose to give poverty reduction highest priority then focus on growth.  Ethiopia’s experience is a case in point for the complex interaction between inequality and growth.  Structural transformation and poverty reduction may require the implementation of reforms that could lead to an increase in income disparities in addition to the growth of economy.  Urban inequality has been given less attention on research and development agenda of Ethiopia particularly for medium towns   like zone and district town of North Shewa Zone. In Ethiopia, annual urban population growth rate is estimated to be above 4.3 %. In line with this income inequality in urban areas income inequality is growing up and the incidence of urban poverty in developing country like Ethiopia is very high.  Thus, the present study aims to identify the determinant and status   of income inequality among urban households of North Shewa Zone Oromia National regional state by using Gini index and multiple regression models on the data collected from 400 respondents.

Educational differences in mortality and hospitalisation for cardiovascular diseases

This paper addresses how the educational gradient in the mortality rate is influenced by the educational difference in hospitalisation for Cardiovascular diseases. We account for possible selective hospitalisation, by using 'Timing-of-events'- model and for selection into education, by using an inverse propensity weighting method. Based on the estimated model we simulate the educational gains of improving education and decompose these educational gains into an indirect effect, running through changes in the hospitalisation process, and a direct effect due to other factors. We use Swedish Military Conscription Data (1951-1960), for males only, linked to administrative Swedish registers. Our empirical results show that the implied educational gains in the survival probability till age 63 are 2% to 5.5%-point, with the largest effect for the low educated. These gains are mainly due educational difference in hospitalisation for the high educated (1.3%-point) and mainly due to other factors (4.9%-point) for the low educated. However, for the (significant) educational gain in implied months lost due premature mortality before age 63 (2 to 9 months) we do not find a significant impact of the educational difference in hospitalisation.

Same, opposite and both-sex attracted adolescents' mental health, safe-sex practices and substance use

This study examined mental health, substance use, and sexual health across sexual attraction groups. 428 adolescents recruited from school-based health centers completed self-report measures. 72% were only opposite-sex attracted, 19% both-sex attracted, 3% same-sex attracted, 4% not sure. Reported partners did not always align with reported attraction. Compared to opposite-sex attracted youth, 1) both-sex attracted youth had significantly higher rates of marijuana use (OR=1.75, p=.04), depressive symptoms (OR=2.62, p=.001) and inconsistent condom use (OR=1.71, p=.05); 2) the "not sure" group had higher anxiety symptoms (OR=4, p=.01). This study highlights the importance of considering sexual attraction in providing quality care to young people.

Public understandings of potential policy responses to health inequalities: Evidence from a UK national survey and citizens' juries in three UK cities

A substantial body of research describes the distribution, causes and potential reduction of health inequalities, yet little scholarship examines public understandings of these inequalities. Existing work is dominated by small-scale, qualitative studies of the experiences of specific communities. As a result, we know very little about what broader publics think about health inequalities; and even less about public views of potential policy responses. This is an important gap since previous research shows many researchers and policymakers believe proposals for 'upstream' policies are unlikely to attract sufficient public support to be viable. This mixed methods study combined a nationally representative survey with three two-day citizens' juries exploring public views of health inequalities and potential policy responses in three UK cities (Glasgow, Manchester and Liverpool) in July 2016. Comparing public opinion elicited via a survey to public reasoning generated through deliberative processes offers insight into the formation of public views. The results challenge perceptions that there is a lack of public support for upstream, macro-level policy proposals and instead demonstrate support for proposals aiming to tackle health inequalities via improvements to living and working conditions, with more limited support for proposals targeting individual behavioural change. At the same time, some macro-economic proposals, notably those involving tax increases, proved controversial among study participants and results varied markedly by data source. Our analysis suggests that this results from three intersecting factors: a resistance to ideas viewed as disempowering (which include, fundamentally, the idea that health inequalities exist); the prevalence of individualising and fatalistic discourses, which inform resistance to diverse policy proposals (but especially those that are more 'upstream', macro-level proposals); and a lack of trust in (local and national) government. This suggests that efforts to enhance public support for evidence-informed policy responses to health inequalities may struggle unless these broader challenges are also addressed.

Excess mortality in Glasgow: further evidence of 'political effects' on population health

OBJECTIVES

The aim of the study was to update previous analyses of 'excess mortality' in Glasgow (Scotland) relative to the similar postindustrial cities of Liverpool and Manchester (England). The excess is defined as mortality after adjustment for socio-economic deprivation; thus, we sought to compare changes over time in both the deprivation profiles of the cities and the levels of deprivation-adjusted mortality in Glasgow relative to the other cities. This is important not only because the original analyses are now increasingly out of date but also because since publication, important (prepandemic) changes to mortality trends have been observed across all parts of the United Kingdom.

STUDY DESIGN AND METHODS

Replicating as far as possible the methods of the original study, we developed a three-city deprivation index based on the creation of spatial units in Glasgow that were of similar size to those in Liverpool and Manchester (average population sizes of approximately 1600, 1500 and 1700 respectively) and an area-based measure of 'employment deprivation'. Mortality and matching population data by age, sex and small area were obtained from national agencies for two periods: 2003-2007 (the period covered by the original study) and 2014-2018. The rates of employment deprivation for each city's small areas were calculated for both periods. Indirectly standardised mortality ratios (SMRs) were calculated for Glasgow relative to Liverpool and Manchester, standardised by age and three-city deprivation decile. For context, city-level trends in age-standardised mortality rates by year, sex and city were also calculated.

RESULTS

There was evidence of a stalling of improvement in mortality rates in all three cities from the early 2010s. After adjustment for area deprivation, all-cause mortality in Glasgow in 2014-2018 was c.12% higher than in Liverpool and Manchester for all ages (SMR 112.4, 95% CI 111.1-113.6) and c.17% higher for deaths under 65 years (SMR 117.1, 95% CI 114.5-119.7). The excess was higher for males (17% compared with 9% for deaths at all ages; 25% compared with 5% for 0-64 years) and for particular causes of death such as suicide and drug-related and alcohol-related causes. The results were broadly similar to those previously described for 2003-2007, although the excess for premature mortality was notably lower. In part, this was explained by changes in levels of employment deprivation, which had decreased to a greater degree in the English cities: this was particularly true of Manchester (a reduction of -43%, compared with -38% in Liverpool and -31% in Glasgow) where the overall population size had also increased to a much greater extent than in the other cities.

CONCLUSIONS

High levels of excess mortality persist in Glasgow. With the political causes recently established - the excess is a 'political effect', not a 'Glasgow effect' - political solutions are required. Thus, previously published recommendations aimed at addressing poverty, inequality and vulnerability in the city are still highly relevant. However, given the evidence of more recent, UK-wide, political effects on mortality - widening mortality inequalities resulting from UK Government 'austerity' measures - additional policies at UK Government level to protect, and restore, the income of the poorest in society are also urgently needed.

Socioeconomic Determinants of Health and Their Unequal Distribution in Poland

The purpose of this study is to identify inequities in the distribution of socioeconomic determinants of health within Poland and their impact on the health status of Poles, as measured by mortality rate. We hypothesised that (1) there are inequities in the socioeconomic characteristics within geographically defined population groups and (2) some socioeconomic determinants of health have a particularly strong impact on the health status of Poles. Poland is administratively divided into three levels: voivodeships, powiats and gminas. We used a dataset covering all 380 powiats in Poland for the year 2018. We employed a two-stage nested Theil index and Herfindahl–Hirschman Index. In order to identify which of these determinants has the strongest impact on health, we conducted a regression analysis. The study revealed some inequities in the distribution of socioeconomic determinants of health. The mortality rate can be partly understood from variations within voivodeships in the distribution of health determinants. Important national inequalities were found in the case of two determinants, which simultaneously proved their significant impact on Poles’ health in the regression analysis. Thus, type of employment and access to modern infrastructure should be of particular concern for public authorities.

Economic relationships and health inequalities: improving public health recommendations

Policy recommendations, which aim to reduce health inequalities in society, often focus upon improving the incomes, working conditions and physical environments of the most deprived groups. We agree with these recommendations but argue that they are insufficient to reduce health inequalities because they fail to address the economic relationships between social groups that lead to health inequalities and which perpetuate them over time. A comprehensive programme to reduce health inequalities will require policies that address the numerous ways in which economic resources flow from poorer groups to richer groups through the design of the economy. In this commentary we describe key economic relationships between social groups that lead to inequalities, namely rent, interest, capital gains, profit, monopoly and speculation. Addressing these causes of economic inequality in recommendations to reduce health inequalities should be considered by future research in this area.

Trends in U.S. Population Health: The Central Role of Policies, Politics, and Profits

Recent trends in U.S. health have been mixed, with improvements among some groups and geographic areas alongside declines among others. Medical sociologists have contributed to the understanding of those disparate trends, although important questions remain. In this article, we review trends since the 1980s in key indicators of U.S. health and weigh evidence from the last decade on their causes. To better understand contemporary trends in health, we propose that commonly used conceptual frameworks, such as social determinants of health, should be strengthened by prominently incorporating commercial, political-economic, and legal determinants. We illustrate how these structural determinants can provide new insights into health trends, using disparate health trajectories across U.S. states as an example. We conclude with suggestions for future research: focusing on structural causes of health trends and inequalities, expanding interdisciplinary perspectives, and integrating methods better equipped to handle the complexity of causal processes driving health trends and inequalities.

'Known to be unhealthy': Exploring how social epidemiological research constructs the category of low socioeconomic status

We examine how the category of low socioeconomic status (LSES) was constructed in European social epidemiological research and policy advice from 1977 to 2019. We analysed 22 empirical social epidemiological research publications on LSES and health, as well as six scientific advisory reports that offered government officials an overview of scientific evidence on health inequalities. We show the construction and reification of LSES as a problematic group in dominant thought, which consists of the following components: 1) the proliferation of SES concepts, indicators and groups labelled LSES; 2) generalisation through which LSES is constructed as a single population; 3) problematisation through which LSES is constructed as an inherently unhealthy population; and 4) individualisation by which a LSES personality is presented as an explanation of health differences. We also show how this knowledge is extrapolated into the policy domain in the form of scientific advisory reports. These findings provide evidence of the construction of LSES as an inherently unhealthy population through hyperproliferation and references to the objectivity of scientific research. With respect to the LSES category, the dynamics of research and policy resemble those regarding categories of ethnicity and gender. We conclude that if the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations 'known to be unhealthy'.

Transforming health systems to reduce health inequalities

Never before in history have we had the data to track such a rapid increase in inequalities. With changes imminent in healthcare and public health organisational landscape in England and health inequalities high on the policy agenda, we have an opportunity to redouble efforts to reduce inequalities. In this article, we argue that health inequalities need re-framing to encompass the breadth of disadvantage and difference between healthcare and health outcome inequalities. Second, there needs to be a focus on long-term organisational change to ensure equity is considered in all decisions. Third, actions need to prioritise the fundamental redistribution of resources, funding, workforce, services and power. Reducing inequalities can involve unpopular and difficult decisions. Physicians have a particular role in society and can support evidenced-based change across practice and the system at large. If we do not act now, then when?

Deaths from 'diseases of despair' in Britain: comparing suicide, alcohol-related and drug-related mortality for birth cohorts in Scotland, England and Wales, and selected cities

Background

The contribution of increasing numbers of deaths from suicide, alcohol-related and drug-related causes to changes in overall mortality rates has been highlighted in various countries. In Scotland, particular vulnerable cohorts have been shown to be most at risk; however, it is unclear to what extent this applies elsewhere in Britain. The aim here was to compare mortality rates for different birth cohorts between Scotland and England and Wales (E&W), including key cities.

Methods

Mortality and population data (1981–2017) for Scotland, E&W and 10 cities were obtained from national statistical agencies. Ten-year birth cohorts and cohort-specific mortality rates (by age of death, sex, cause) were derived and compared between countries and cities.

Results

Similarities were observed between countries and cities in terms of peak ages of death, and the cohorts with the highest death rates. However, cohort-specific rates were notably higher in Scotland, particularly for alcohol-related and drug-related deaths. Across countries and cities, those born in 1965–1974 and 1975–1984 had the highest drug-related mortality rates (peak age at death: 30–34 years); the 1965–1974 birth cohort also had the highest male suicide rate (peak age: 40–44 years). For alcohol-related causes, the highest rates were among earlier cohorts (1935–1944, 1945–1954, 1955–1964)—peak age 60–64 years.

Conclusions

The overall similarities suggest common underlying influences across Britain; however, their effects have been greatest in Scotland, confirming greater vulnerability among that population. In addressing the socioeconomic drivers of deaths from these causes, the cohorts identified here as being at greatest risk require particular attention.

Trends in socioeconomic inequalities in premature and avoidable mortality in Canada, 1991-2016

BACKGROUND

Recent epidemiologic findings suggest that socioeconomic inequalities in health may be widening over time. We examined trends in socioeconomic inequalities in premature and avoidable mortality in Canada.

METHODS

We conducted a population-based repeated cohort study using the 1991, 1996, 2001, 2006 and 2011 Canadian Census Health and Environment Cohorts. We linked individual-level Census records for adults aged 25-74 years to register-based mortality data. We defined premature mortality as death before age 75 years. For each census cohort, we estimated age-standardized rates, risk differences and risk ratios for premature and avoidable mortality by level of household income and education.

RESULTS

We identified 16 284 045 Census records. Between 1991 and 2016, premature mortality rates declined in all socioeconomic groups except for women without a high school diploma. Absolute income-related inequalities narrowed among men (from 2478 to 1915 deaths per 100 000) and widened among women (from 1008 to 1085 deaths per 100 000). Absolute education-related inequalities widened among men and women. Relative socioeconomic inequalities in premature mortality widened progressively over the study period. For example, the relative risk of premature mortality associated with the lowest income quintile increased from 2.10 (95% confidence interval [CI] 2.02-2.17) to 2.79 (95% CI 2.66-2.91) among men and from 1.72 (95% CI 1.63- 1.81) to 2.50 (95% CI 2.36-2.64) among women. Similar overall trends were observed for avoidable mortality.

INTERPRETATION

Socioeconomically disadvantaged groups have not benefited equally from recent declines in premature and avoidable mortality in Canada. Efforts to reduce socioeconomic inequalities and associated patterns of disadvantage are necessary to prevent this pattern of widening health inequalities from persisting or worsening over time.

Did Expanded Dental Insurance Reduce Out-of-Pocket Expenditures on Dental Care among Older Adults in Korea? Interrupted Time-Series Analysis

The Korean National Health Insurance extended its coverage to reduce the economic burden of receiving dentures and implants for older adults in 2012 and 2014, respectively. We examined whether the new policy resulted in reduced out-of-pocket dental care expenditure in the eligible population, specifically focusing on low-income adults. We used interrupted time-series analysis (ITSA), a quasi-experimental design, to identify the effects of the policy among persons aged 65 or older. Data were extracted from the Korea Health Panel Survey (KHP; 2008–2017). The main outcome was out-of-pocket expenditures on dental care. The ITSA showed that expenditures decreased annually by 4.5% (RR: 0.96, 95% CI: 0.95–0.96) between 2012 and 2014. However, expenditure increased by 7.8% (RR: 1.08, 95% CI: 1.07–1.08) after 2014. Dental insurance coverage did not contribute to reducing the out-of-pocket expenses for dentures among low-income adults, while coverage of dental implants led to an increase in dental expenditure.

Health Inequalities During COVID-19 and Their Effects on Morbidity and Mortality

Inequalities in health have existed for many decades and have led to unjust consequences in morbidity and mortality. These have become even more apparent during the COVID-19 pandemic with individuals from black and minority ethnic groups, poorer socioeconomic backgrounds, urban and rurally deprived locations, and vulnerable groups of society suffering the full force of its effects. This review is highlighting the current disparities that exist within different societies, that subsequently demonstrate COVID-19, does in fact, discriminate against disadvantaged individuals. Also explored in detail are the measures that can and should be taken to improve equality and provide equitable distribution of healthcare resources amongst underprivileged communities.

Health inequalities, fundamental causes and power: towards the practice of good theory

Reducing health inequalities remains a challenge for policy makers across the world. Beginning from Lewin's famous dictum that "there is nothing as practical as a good theory", this paper begins from an appreciative discussion of 'fundamental cause theory', emphasizing the elegance of its theoretical encapsulation of the challenge, the relevance of its critical focus for action, and its potential to support the practical mobilisation of knowledge in generating change. Moreover, it is argued that recent developments in the theory, provide an opportunity for further theoretical development focused more clearly on the concept of power (Dickie et al. 2015). A critical focus on power as the essential element in maintaining, increasing or reducing social and economic inequalities - including health inequalities - can both enhance the coherence of the theory, and also enhance the capacity to challenge the roots of health inequalities at different levels and scales. This paper provides an initial contribution by proposing a framework to help to identify the most important sources, forms and positions of power, as well as the social spaces in which they operate. Subsequent work could usefully test, elaborate and adapt this framework, or indeed ultimately replace it with something better, to help focus actions to reduce inequalities.

US State Polarization, Policymaking Power, and Population Health

Policy Points Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high-income countries must address those factors. Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes.

Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge?

BACKGROUND

The mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public.

METHODS

We compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations.

RESULTS

Mortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of -5.96 years for the UK. This is reduced to -0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are -0.25, -0.20 and -3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK.

CONCLUSION

Fully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to 'build back better'.

Scaling COVID-19 against inequalities: should the policy response consistently match the mortality challenge?

BACKGROUND

The mortality impact of COVID-19 has thus far been described in terms of crude death counts. We aimed to calibrate the scale of the modelled mortality impact of COVID-19 using age-standardised mortality rates and life expectancy contribution against other, socially determined, causes of death in order to inform governments and the public.

METHODS

We compared mortality attributable to suicide, drug poisoning and socioeconomic inequality with estimates of mortality from an infectious disease model of COVID-19. We calculated age-standardised mortality rates and life expectancy contributions for the UK and its constituent nations.

RESULTS

Mortality from a fully unmitigated COVID-19 pandemic is estimated to be responsible for a negative life expectancy contribution of -5.96 years for the UK. This is reduced to -0.33 years in the fully mitigated scenario. The equivalent annual life expectancy contributions of suicide, drug poisoning and socioeconomic inequality-related deaths are -0.25, -0.20 and -3.51 years, respectively. The negative impact of fully unmitigated COVID-19 on life expectancy is therefore equivalent to 24 years of suicide deaths, 30 years of drug poisoning deaths and 1.7 years of inequality-related deaths for the UK.

CONCLUSION

Fully mitigating COVID-19 is estimated to prevent a loss of 5.63 years of life expectancy for the UK. Over 10 years, there is a greater negative life expectancy contribution from inequality than around six unmitigated COVID-19 pandemics. To achieve long-term population health improvements it is therefore important to take this opportunity to introduce post-pandemic economic policies to 'build back better'.

An atlas of health inequalities and health disparities research: "How is this all getting done in silos, and why?"

Research on health inequalities and health disparities has grown exponentially since the 1960s, but this expansion has not been matched by an associated sense of progress. Criticisms include claims that too much research addresses well-trodden questions and that the field has failed to gain public and policy traction. Qualitative studies have found researchers partly attribute these challenges to fragmentation resulting from disciplinary and methodological differences. Yet, empirical investigation ('research on research') is limited. This study addresses this gap, employing mixed-methods to examine, at scale, how and why this field is defined by insular research clusters. First, bibliometric analysis identifies and visualizes the 250 most-connected authors. Next, an algorithm was used to identify clustering via citation links between authors. We used researcher profiling to ascertain authors' geographical and institutional locations and disciplinary training, examining how this mapped onto clusters. Finally, causes of siloing were investigated via semi-structured interviews with 45 researchers. The resulting 'atlas' of health inequalities and health disparities research identifies eight clusters of authors with varying degrees of connectedness. No single factor neatly describes observed fragmentation, health equity scholars exhibit a diverse disciplinary backgrounds, and geographical, institutional, and historical factors appear to intersect to explain siloed citation patterns. While the configuration of research activity within clusters potentially helps render questions scientifically manageable, it affirms perceptions of the field as fragmented. We draw on Thomas Kuhn and Sheila Jasanoff to position results within theoretical pictures of scientific progress. Newcomers to the field can use our findings to orient themselves within the many streams of health equity scholarship, and existing health equity scholars can use the atlas to move beyond existing geo-disciplinary networks. However, although stronger cross-cluster engagement would be likely to improve insights, the complex nexus of factors underlying the field's structure will likely make this challenging in practice.

Poverty and mental health: policy, practice and research implications

This article examines the relationship between poverty and mental health problems. We draw on the experience of Glasgow, our home city, which contains some of Western Europe's areas of greatest concentrated poverty and poorest health outcomes. We highlight how mental health problems are related directly to poverty, which in turn underlies wider health inequalities. We then outline implications for psychiatry.

Individual-level factors attributable to urban-rural disparity in mortality among older adults in China

BACKGROUND

Urban-rural disparity in mortality at older ages is well documented in China. However, surprisingly few studies have systemically investigated factors that contribute to such disparity. This study examined the extent to which individual-level socioeconomic conditions, family/social support, health behaviors, and baseline health status contributed to the urban-rural difference in mortality among older adults in China.

METHODS

This research used the five waves of the Chinese Longitudinal Healthy Longevity Survey from 2002 to 2014, a nationally representative sample of older adults aged 65 years or older in China (n = 28,235). A series of hazard regression models by gender and age group examined the association between urban-rural residence and mortality and how this association was modified by a wide range of individual-level factors.

RESULTS

Older adults in urban areas had 11% (relative hazard ratio (HR) = 0.89, p < 0.01) lower risks of mortality than their rural counterparts when only demographic factors were taken into account. Further adjustments for family/social support, health behaviors, and health-related factors individually or jointly had a limited influence on the mortality differential between urban and rural older adults (HRs = 0.89-0.92, p < 0.05 to p < 0.01). However, we found no urban-rural difference in mortality (HR = 0.97, p > 0.10) after adjusting for individual socioeconomic factors. Similar results were found in women and men, and among the young-old and the oldest-old populations.

CONCLUSIONS

The urban-rural disparity in mortality among older adults in China was largely attributable to differences in individual socioeconomic resources (i.e., education, income, and access to healthcare) regardless of gender and age group.

"The state They're in": Unpicking fantasy paradigms of health improvement interventions as tools for addressing health inequalities

Globally, it is recognised that the fundamental causes of iniquitous health outcomes lie within unequal distributions of wealth and power. Internationally, however, policies and interventions persist in individualising the inequalities problem and targeting individual behaviours as the main solution. This approach has been argued to represent 'Fantasy Paradigms'. This paper explores one example of such 'Fantasy' intervention from the perspective of health practitioners. Further, it explores opportunities for deepening practitioner understandings of the socio-political determination of health. Data were collected through in-depth interviews with 47 professionals involved in delivering a social prescribing programme in poor areas of Glasgow, Scotland. Data were analysed thematically across and within transcripts. Narratives highlighted different explanatory types concerning how the intervention could tackle health inequalities including: firm commitment to individualised approaches; hopeful pessimism; the social-determinants-of-health as an unpoliticised and nondeterministic backdrop to poor health; and finally, incomplete understanding of the social gradient as a population concept. Disrupted narratives of the social determination of health were also evident. This paper contributes new insights to existing debates on health inequalities discourse. These are conceptually important and identify opportunities for sharpening practitioner understanding of the social determinants of health which could in turn contribute to better, non-stigmatising primary care. It argues that re-engaging communities of practice with what is meant by determination of health is necessary and that there is a need to de-couple the policy aim of reducing health inequalities from the delivery of structurally competent and equality-focused public services.

Urban inequalities in the 21st century economy

In the last decade or so, inequality studies have assumed renewed prominence across the social sciences. In this introduction to a special issue of Applied Geography, we set out to articulate the importance of urban spatial context in broader present-day inequality debates. We argue that the information-based economy is emphatically urban-based and that it has forged new spatial inequalities in and between cities and among urban populations. Income gaps have widened, inter-city disparities have grown, suburbs have been re-sorted into a wide array on the basis of class and race or ethnicity, and many central cities have assumed a renewed importance within metropolitan areas. We argue that attention to urban spatial dimensions at various scales is critical to understanding current inequality trends, from intra-urban to regional and global scales. Contributions to this special issue from North America, Europe, South America, and China suggest that deepening urban inequalities are pervasive across the globe.

The effect of income-based policies on mortality inequalities in Scotland: a modelling study

BACKGROUND

The unequal distribution of income is a fundamental determinant of health inequalities. Decision making around economic policies could be enhanced by showing their potential health effects. We used scenario modelling to assess the effects of 12 income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017-21 period.

METHODS

In this modelling study, we used EUROMOD version H1.0+, a tax-benefit microsimulation model, to estimate the effects of hypothetical fiscal policies on household income for Scottish households in the 2014/15 Family Resources Survey (n=2871). The effects were modelled excluding housing costs. Income change from baseline was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation (SIMD) after weighting to account for differential non-response to the Family Resources Survey, and incomes were equivalised according to the Organisation for Economic Co-operation and Development's modified equivalence scale. A regression analysis of cross-sectional data was used to estimate the relationship between income change and all-cause mortality, followed up by a sensitivity analysis to account for uncertainties around the assumptions on effect size. Informing Interventions to reduce health Inequalities (Triple I), a health inequalities scenario modelling tool, was used to estimate policy effects on YLL and government spending after five years of theoretical implementation. The Triple I model used population estimates for 2016 stratified by sex, 5-year age group, and SIMD quintile, which were obtained from the National Records of Scotland. Preliminary estimates of relative policy costs were calculated from the EUROMOD-derived combined effects of each policy on tax bills, National Insurance contributions, and benefits receipts for Scottish households.

FINDINGS

Taxation-based policies did not substantially affect household incomes, whereas benefits-based policies had large effects across the quintiles. The best policy for improving health and narrowing health inequalities was a 50% increase to means-tested benefits (approximately 105 177 [4·7%] YLL fewer than the baseline of 2·2 million, and a 7·9% reduction in relative index of inequality). Effects on YLL and health inequalities were inversely correlated in response to changes in taxation policy. Citizen's Basic Income (CBI) schemes also substantially narrowed inequalities (3·7% relative index of inequality for basic scheme, 5·9% for CBI with additional payments for individuals with disability), and modestly reduced YLL (0·7% for the basic scheme and 1·4% with additional payments). The estimated government spending associated with a policy was proportional to its effect on YLL, but less closely related to its effect on inequalities in YLL.

INTERPRETATION

Policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland. Our projections suggest that the most effective policies for reducing health inequalities appeared to be those that disproportionately increased incomes in the most deprived areas. Although modelling was subject to various assumptions, the approach can be useful to inform decisions around addressing the upstream determinants of health inequalities.

FUNDING

None.

Socioeconomic gradients of adverse birth outcomes and related maternal factors in rural and urban Alberta, Canada: a concentration index approach

OBJECTIVE

Using a summary measure of health inequalities, this study evaluated the distribution of adverse birth outcomes (ABO) and related maternal risk factors across area-level socioeconomic status (SES) gradients in urban and rural Alberta, Canada.

DESIGN

Cross-sectional study using a validated perinatal clinical registry and an area-level SES.

SETTING

The study was conducted in Alberta, Canada. Data about ABO and related maternal risk factors were obtained from the Alberta Perinatal Health Program between 2006 and 2012. An area-level SES index derived from census data (2006) was linked to the postal code at delivery.

PARTICIPANTS

Women (n=3 30 957) having singleton live births with gestational age ≥22 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated concentration indexes to assess inequalities across SES gradients in both rural and urban areas (CIdx_R and CIdx_U, respectively) for spontaneous preterm birth (PTB), small for gestational age (SGA), large for gestational age (LGA), gestational hypertension, gestational diabetes, smoking and substance use during pregnancy and pre-pregnancy weight >91 kg.

RESULTS

The highest health inequalities disfavouring low SES groups were identified for substance abuse and smoking in rural areas (CIdx_R-0.38 and -0.23, respectively). Medium inequalities were identified for LGA (CIdx_R-0.08), pre-pregnancy weight >91 kg (CIdx_R-0.07), substance use (CIdx_U-0.15), smoking (CIdx_U-0.14), gestational diabetes (CIdx_U-0.10) and SGA (CIdx_U-0.07). Low inequalities were identified for PTB (CIdx_R-0.05; CIdx_U-0.05) and gestational diabetes (CIdx_R-0.04). Inequalities disfavouring high SES groups were identified for gestational hypertension (CIdx_R+0.04), SGA (CIdx_R+0.03) and LGA (CIdx_U+0.03).

CONCLUSIONS

ABO and related maternal risk factors were unequally distributed across the socioeconomic gradient in urban-rural settings, with the greatest concentrations in lower SES groups of rural areas. Future research is needed on underlying mechanisms driving SES gradients in perinatal health across the rural-urban spectrum.

Socio-economic status, self-rated health and mental health: the mediation effect of social participation on early-late midlife and older adults

Background

Socioeconomic status (SES) is a major determinant of diverse health outcomes, among these are self-rated-health and mental health. Yet the mechanisms underlying the SES—health relation are not fully explored. Socioeconomic inequalities in health and mental health may form along several pathways. One is social participation which is linked to better self-rated-health and mental health. We examined (1) whether various social participation practices, including the usage of information and communication technology, relate to a unidimensional or multidimensional phenomenon (2) the relationship among SES, social participation, self-rated-health and mental health; (3) whether social participation and mental health mediates the association between SES and self-rated-health; (4) whether social participation and self-rated-health mediates the links between SES and mental health.

Method

Cross-sectional data for individuals aged 35 and older were taken from the Israeli Social Survey for 2016 (N = 4848). Social participation practices included connection with family and friends, self-perceived-support, self-perceived trust, volunteering, civic and political involvement, and information and communication technology usage. An exploratory factor analysis was conducted for all social participation practices. We then constructed structural Equation Modeling (SEM) to explore paths of relations among SES, social participation, self-rated-health and mental health.

Results

We found disparities in self-rated health and mental health across SES. Social participation practice, ‘frequency of meeting with friends’, mediated the links between SES-self-rated health and SES-mental health. Formal social participation practices along with internet usage mediated the SES- self-rated health link. Informal social participation practices and self-perceived trust mediated the SES-mental health link. Mental health mediated the SES- self-rated health link and self-rated health mediated the SES-mental health link.

Conclusion

The links between SES and the two health constructs were enhanced by common and distinct social participation practices. Enhancement of social participation practices among low SES individuals is recommended. Social participation should be a prominent aspect of preventive medicine practice and health promotion interventions. Policy makers are called to support such programs as an important way to promote public health.

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.