Intersectional inequalities in mental health across multiple dimensions of inequality in the Swedish adult population

Ethnic discrimination and mental health in the Sámi population in Sweden: The SámiHET study

AIMS

To assess the association between experiences of discrimination and mental health among the Sámi population in Sweden.

METHODS

Cross-sectional study among the self-identified Sámi population living in Sweden in 2021, registered in the electoral roll of the Sámi Parliament, the reindeer mark register and the 'Labour statistics based on administrative sources'. The analysis was based on a final sample of 3658 respondents aged between 18 and 84 years. Adjusted prevalence ratios aPRs for psychological distress (Kessler scale), self-reported anxiety and depression were estimated for four different forms of discrimination (direct experience of discrimination, offended because of ethnicity, historical trauma, and combined discrimination).

RESULTS

Higher aPRs of psychological distress, anxiety and depression were observed in women experiencing direct discrimination because of their ethnicity, having been offended because of their ethnicity, and those with a family history of discrimination. Among men, higher aPRs for psychological distress were observed in those experiencing the four different forms of discrimination, but not for anxiety. Depression was only detected in the case of having been offended. Adding experiences of discrimination was associated with a higher prevalence of negative outcomes for all the indicators in women and for psychological distress in men.

CONCLUSIONS

The observed association between experiences of discrimination and mental health problems would support a gender approach when considering ethnic discrimination in public health policies concerning the Sámi in Sweden.

Psychological Distress in Low-Income and Economically Marginalized Populations in India: Protective and Risk Factors

Studies at the juncture of development economics and public health take on considerable responsibility in addressing inequality and related mental health distress. Mental healthcare in economically marginalized populations requires depicting the linkages between socioeconomic status and psychological distress. In the present work, a sequential mixed-methods design was used to study 190 people in such communities in India. Gender-dependent psychological distress was found according to the Kessler Psychological Distress Scale (K-10) with moderate distress in women (M = 26.30, SD = 9.15) and mild distress in men (M = 21.04, SD = 8.35). Regression analysis indicated that gender significantly predicted psychological distress, followed by age, marital status, and the level of education of the head of the family. The Interpretative Phenomenological Analysis of semi-structured interviews of the six women who scored the highest on the distress scale unveiled three master themes: (1) manifestation of psychological distress, (2) contextual challenges, and (3) sources of strength and resilience. Overall, participants reported a lack of resources, community violence, gender discrimination, and widespread substance use as major contributors to the ongoing distress. These findings can pave the way for future studies to expand beyond independent economic indicators and curate clinical interventions for culturally competent mental healthcare.

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010-2016

INTRODUCTION

Mental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This study investigates racial and socioeconomic inequalities in primary healthcare usage, hospitalisation and mortality for mental health disorders in Rio de Janeiro, Brazil.

METHODS

A cohort of 1.2 million low-income adults from Rio de Janeiro, Brazil with linked socioeconomic, demographic, healthcare use and mortality records was cross-sectionally analysed. Poisson regression models were used to investigate associations between self-defined race/colour and primary healthcare (PHC) usage, hospitalisation and mortality due to mental disorders, adjusting for socioeconomic factors. Interactions between race/colour and socioeconomic characteristics (sex, education level, income) explored if black and pardo (mixed race) individuals faced compounded risk of adverse mental health outcomes.

RESULTS

There were 272 532 PHC consultations, 10 970 hospitalisations and 259 deaths due to mental disorders between 2010 and 2016. After adjusting for a wide range of socioeconomic factors, the lowest PHC usage rates were observed in black (adjusted rate ratio (ARR): 0.64; 95% CI 0.60 to 0.68; compared with white) and pardo individuals (ARR: 0.87; 95% CI 0.83 to 0.92). Black individuals were more likely to die from mental disorders (ARR: 1.68; 95% CI 1.19 to 2.37; compared with white), as were those with lower educational attainment and household income. In interaction models, being black or pardo conferred additional disadvantage across mental health outcomes. The highest educated black (ARR: 0.56; 95% CI 0.47 to 0.66) and pardo (ARR: 0.75; 95% CI 0.66 to 0.87) individuals had lower rates of PHC usage for mental disorders compared with the least educated white individuals. Black individuals were 3.7 times (ARR: 3.67; 95% CI 1.29 to 10.42) more likely to die from mental disorders compared with white individuals with the same education level.

CONCLUSION

In low-income individuals in Rio de Janeiro, racial/colour inequalities in mental health outcomes were large and not fully explainable by socioeconomic status. Black and pardo Brazilians were consistently negatively affected, with lower PHC usage and worse mental health outcomes.

The intersections of socioeconomic position, gender, race/ethnicity and nationality in relation to oral conditions among American adults

OBJECTIVE

The objective of the study was to evaluate how gender, socioeconomic position (SEP), race/ethnicity and nationality intersect to structure social inequalities in adult oral health among American adults.

METHODS

Data from adults aged 20 years or over who participated in the National Health and Nutrition Examination Survey (NHANES) 2009-2018 were analysed. The outcomes were poor self-rated oral health and edentulism among all adults (n = 24 541 and 21 446 participants, respectively) and untreated caries and periodontitis among dentate adults (n = 16 483 and 9829 participants, respectively). A multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) was conducted for each outcome, by nesting individuals within 48 intersectional strata defined as combinations of gender, SEP, race/ethnicity and nationality. Intersectional measures included the variance partition coefficient (VPC), the proportional change in variance (PCV) and predicted excess probability due to interaction.

RESULTS

Substantial social inequalities in the prevalence of oral conditions among adults were found, which were characterized by high between-stratum heterogeneity and outcome specificity. The VPCs of the simple intersectional model showed that 9.4%-12.7% of the total variance in the presentation of oral conditions was attributed to between-stratum differences. In addition, the PCVs from the simple intersectional model to the intersectional interaction model showed that 84.1%-97.1% of the stratum-level variance in the presentation of oral conditions was attributed to the additive effects of gender, SEP, race/ethnicity and nationality. The point estimates of the predictions for some intersectional strata were suggestive of an intersectional interaction effect. However, the 95% credible intervals were very wide and the estimations inconclusive.

CONCLUSIONS

This analysis highlights the value of the intersectionality framework to understand heterogeneity in social inequalities in oral health. These inequalities were mainly due to the additive effect of the social identities defining the intersectional strata, with no evidence of interaction effects.

Gender inequalities in the prevalence of low mood and related factors in schooled adolescents during the 2019-2020 school year: DESKcohort project

BACKGROUND

Mood disorders are the second most prevalent mental disorders in childhood and adolescence. Many undiagnosed people manifest subthreshold symptoms, like low mood, and present worse prognoses than asymptomatic healthy subjects. The aim of this study was to estimate the prevalence of low mood, gender inequalities, and associated factors, in 12- to 18-year-old adolescents in the rural and medium-sized urban areas of Central Catalonia during the 2019-2020 academic year.

METHODS

Cross-sectional study with data from a cohort of high-schooled students (2019-2020), with a convenience sample of 6428 adolescents from the Central region of Catalonia (48.3 % boys and 51.7 % girls). Prevalence of low mood was estimated by gender and exposure variables, and ratios were obtained using Poisson regression models, adjusting for several exposure variables one by one, and for all of them jointly.

RESULTS

The prevalence of low mood was 18.6 %, with statistically significant differences between genders (11.6 %, 95 % CI: 10.5-12.8 in boys and 25.1 %, 95 % CI: 23.7-26.6 in girls). Being an immigrant, dieting, and daily tobacco smoking were only associated with low mood in girls, whereas risky alcohol consumption was only associated in boys. Sexual violence was found to account for 36.2 % of low mood problems in girls.

LIMITATIONS

The main limitation of the study is its cross-sectional design, which means that no casual relationships can be extracted of this study.

CONCLUSIONS

The prevalence of low mood varies between the sexes, highlighting the importance of developing gender-specific interventions to reduce its incidence in young people, considering the factors associated with this condition.

Assessing inequities in unmet oral care needs among adults in Sweden: An intersectional approach

OBJECTIVES

The goal of the Swedish oral healthcare system is to achieve good oral health and equitable access to care for the entire population. However, considerable inequities in oral health and care are evident and occur across a range of social dimensions. This study uses an intersectional approach to examine complex inequities in unmet oral care needs among adults in Sweden over the period 2004-2021.

METHODS

Data were obtained from 14 Health on Equal Terms surveys conducted during 2004-2021. The final sample was 129 473 individuals aged 26-84 years. Applying intersectional analysis of individual heterogeneity and discriminatory accuracy, inequities in unmet oral care needs were estimated across 48 intersectional strata defined by gender, age, educational level, individual disposable income and immigrant status.

RESULTS

A high risk of unmet oral care needs was found among strata consisting of immigrants and those with low income. However, being an immigrant and/or having a low income did not universally entail a high risk but varied by the social position along other axes, particularly age and education. The discriminatory accuracy was moderate.

CONCLUSION

Groups with certain social disadvantages are highly heterogeneous themselves. An intersectionality approach is important to prevent the risk of stigmatizing large heterogenous groups while failing to identify the most vulnerable strata. The discriminatory accuracy analysis suggested that further policy and/or interventions may be the most effective if approaching the whole population, combined with selected targeted interventions directed at the most disadvantaged social strata.

Disparities in fruit and vegetable intake at the intersection of gender and education in northern Sweden: a cross-sectional study

BACKGROUND

Even though the existence of inequalities in fruit and vegetable consumption has been well established, it is not clear how it is patterned across intersections of multiple social positions and identities. This study aims to investigate disparities in fruit and vegetable intake between groups at the intersection of education and gender in northern Sweden, and to estimate the discriminatory accuracy of the intersectional groups.

METHODS

Cross-sectional data from the 2018 Health on Equal Terms survey conducted in four regions in northern Sweden was used (N = 21,853). Four intersectional groups were created: high and low educated men, and high and low educated women. Prevalence differences corresponding to joint, referent, and excess intersectional inequalities, were estimated for three outcomes: inadequate fruit and vegetable intake combined, inadequate fruit intake, and inadequate vegetable intake. The discriminatory accuracy of the intersectional groups was estimated by the area under the receiver operating characteristic curve.

RESULTS

Low educated men had the highest prevalence of inadequate intake of fruits and vegetables combined (81.4%), fruits (83.4%), and vegetables (84.9%), while high educated women had the lowest (47.7, 60.2, and 51.8%, respectively). The joint disparities between high educated women and low educated men were both significant and substantial for all outcomes (34.6 percentage points (pp.), 25.2 pp., and 31.2 pp., adjusted), although differences in magnitude were noted between fruit and vegetable intake. The joint disparities were mostly explained by the two referent disparities for gender and education. The excess intersectional disparity - the part of the joint disparity not explained by either referent disparity - was negative for all three outcomes (-5.5 pp., - 4.2 pp., and - 4.6 pp. respectively, adjusted). The discriminatory accuracy of the intersectional groups was moderate (0.67, 0.65, and 0.68 respectively).

CONCLUSIONS

An intersectional approach can provide a more detailed view of inequalities in fruit and vegetable consumption between groups combining several social positions. The moderate discriminatory accuracy observed here suggests that interventions and policies aiming to reduce diet inequalities should not solely be targeted at certain groups, but also be universal.

An Exploratory Study of Gender Role Stress and Psychological Distress of Women in Kosovo

INTRODUCTION

Although investigations of changing gender roles have been performed globally, most studies have been conducted in high-income countries, and studies from emerging and developing countries are lacking. This study aims to examine the factor structure of the feminine gender role stress scale among women (FGRS) and explore its relationship with psychological distress (PD).

METHODS

A cross-sectional study was carried out with 656 women from Kosovo using a convenience sampling technique during October 2017 and March 2018. The data were collected through face-to-face interviews and analyzed using the Statistical Package for the Social Sciences version 21 and Mplus 7.3. Confirmatory factor analysis (CFA) and path analysis were used to understand the goodness-of-fit of the FGRS scale in the Kosovo context and explore the relationship between the FGRS scale and PD when treated as latent variables. Multivariance analysis of variance (ANOVA) was used to understand the differences between groups of women based on employment and FGRS. Multinomial logistic regression was used to assess the prediction of different domains of FGRS for PD separately for each category while controlling for age.

RESULTS

After demonstrating that the five-factor model of the FGRS showed a good fit to the data in this sample of Kosovo women, analyses revealed that the FGRS domains (fear of victimization and behaving with assertiveness) were positively associated with psychological distress.

CONCLUSION

The findings validate the usefulness of the FGRS scale in a sample of Kosovar women. The intersectionality perspective was used to interpret the importance of multiple layers of vulnerabilities and their coexistence, including education, socioeconomic status, and their implications for health inequalities.