Effects of restrictions to Income Support on health of lone mothers in the UK: a natural experiment study

Is Austerity Responsible for the Stalled Mortality Trends Across Many High-Income Countries? A Systematic Review

This article systematically reviews evidence evaluating whether macroeconomic austerity policies impact mortality, reviewing high-income country data compiled through systematic searches of nine databases and gray literature using pre-specified methods (PROSPERO registration: CRD42020226609). Eligible studies were quantitatively assessed to determine austerity's impact on mortality. Two reviewers independently assessed eligibility and risk of bias using ROBINS-I. Synthesis without meta-analysis was conducted due to heterogeneity. Certainty of evidence was assessed using the GRADE framework. Of 5,720 studies screened, seven were included, with harmful effects of austerity policies demonstrated in six, and no effect in one. Consistent harmful impacts of austerity were demonstrated for all-cause mortality, life expectancy, and cause-specific mortality across studies and different austerity measures. Excess mortality was higher in countries with greater exposure to austerity. Certainty of evidence was low. Risk of bias was moderate to critical. A typical austerity dose was associated with 74,090 [-40,632, 188,792] and 115,385 [26,324, 204,446] additional deaths per year. Austerity policies are consistently associated with adverse mortality outcomes, but the magnitude of this effect remains uncertain and may depend on how austerity is implemented (e.g., balance between public spending reductions or tax rises, and distributional consequences). Policymakers should be aware of potential harmful health effects of austerity policies.

Social security cuts and life expectancy: a longitudinal analysis of local authorities in England, Scotland and Wales

BACKGROUND

The UK Government's 'welfare reform' programme included reductions to social security payments, phased in over the financial years 2011/2012-2015/2016. Previous studies of social security cuts and health outcomes have been restricted to analysing single UK countries or single payment types (eg, housing benefit). We examined the association between all social security cuts fully implemented by 2016 and life expectancy, for local authorities in England, Scotland and Wales.

METHODS

Our unit of analysis was 201 upper tier local authorities (unitary authorities and county councils: 147 in England, 32 in Scotland, 22 in Wales). Our exposure was estimated social security loss per head of the working age population per year for each local authority, calculated against the baseline in 2010/2011. The primary outcome was annual life expectancy at birth between the calendar years 2012 and 2016 (year lagged following exposure). We used a panel regression approach with fixed effects.

RESULTS

Social security cuts implemented by 2016 were estimated to be £475 per head of the working age population in England, £390 in Scotland and £490 in Wales since 2010/2011. During the study period, there was either no improvement or only marginal increases in national life expectancy. Social security loss and life expectancy were significantly associated: an estimated £100 decrease in social security per head of working age population was associated with a 1-month reduction in life expectancy.

CONCLUSIONS

Social security cuts, at the UK local authority level, were associated with lower life expectancy. Further research should examine causality.

Understanding the Relationship Between Decreases in Social Security Benefits and Intergenerational Inequalities in Mental Health

It is well-established that mental health follows similar patterns across generations. However, little is known how structural factors, such as those related to social security reforms, may impact this relationship. Our aim was to quantify the strength of association in mental health between parents and their adolescent children, and to explore how much of this correlation is explained by decreases in benefits. We used data from U.K. Household Longitudinal Study (2009-2019) from which we matched youth data to their parents, and split the sample into single- and dual-parent households. To estimate the intergenerational correlations, we estimated a series of unit- and rank-based regression models of standardized and time-averaged mental health measures for adolescents and their parents. Our findings suggest that there are statistically significant intergenerational associations in mental health between parents and children for both single- and dual-parent households, with the relationship being stronger for single-mother households. Benefit losses explain a small proportion of this association, for both single-mother and dual-parent households. Nevertheless, they are negatively associated with the mental health of adolescents in dual-parent households-independently of both adolescent and parental characteristics. Such negative effects should be considered when designing and evaluating future social security benefit policies.

Identifying opportunities for upstream evaluations relevant to child and maternal health: a UK policy-mapping review

OBJECTIVE

Interventions to tackle the social determinants of health can improve outcomes during pregnancy and early childhood, leading to better health across the life course. Variation in content, timing and implementation of policies across the 4 UK nations allows for evaluation. We conducted a policy-mapping review (1981-2021) to identify relevant UK early years policies across the social determinants of health framework, and determine suitable candidates for evaluation using administrative data.

METHODS

We used open keyword and category searches of UK and devolved Government websites, and hand searched policy reviews. Policies were rated and included using five criteria: (1) Potential for policy to affect maternal and child health outcomes; (2) Implementation variation across the UK; (3) Population reach and expected effect size; (4) Ability to identify exposed/eligible group in administrative data; (5) Potential to affect health inequalities. An expert consensus workshop determined a final shortlist.

RESULTS

336 policies and 306 strategy documents were identified. Policies were mainly excluded due to criteria 2-4, leaving 88. The consensus workshop identified three policy areas as suitable candidates for natural experiment evaluation using administrative data: pregnancy grants, early years education and childcare, and Universal Credit.

CONCLUSION

Our comprehensive policy review identifies valuable opportunities to evaluate sociostructural impacts on mother and child outcomes. However, many potentially impactful policies were excluded. This may lead to the inverse evidence law, where there is least evidence for policies believed to be most effective. This could be ameliorated by better access to administrative data, staged implementation of future policies or alternative evaluation methods.

Lone parents' employment policy and adolescents' socioemotional development: Quasi-experimental evidence from a UK reform

Studies suggest that welfare-to-work programmes increase lone mother's employment, but their impact on child and adolescent socioemotional development is unclear. The lone parent obligation (LPO) reform introduced a requirement for lone mothers entitled to unconditional Income Support (IS) to seek paid work actively as a condition to receive benefits. We use data from the UK Millennium Cohort Study to examine the impact of work search requirements for lone parents on child and adolescent socioemotional development. We apply a difference-in-differences approach that exploits gradual changes from 2008 to 2017 in children's maximum eligibility age to receive IS and assess effects on child and adolescent Strengths and Difficulties Questionnaire (SDQ) scores. We find that the LPO reform led to a ten-percentage point increase in lone mothers' employment but no change in the risk of family poverty. The reform led to a small but statistically significant increase in adolescents' SDQ scores, which indicated worse mental health and was largely driven by increased emotional problems. It also led to an increase in mothers' distress and poor self-rated health, and mothers' reports that time spent with children was insufficient. Our findings highlight the need to consider trade-offs between employment gains and child and adolescent socioemotional development in assessing the net impact of welfare-to-work policies targeting lone parents.

Is austerity a cause of slower improvements in mortality in high-income countries? A panel analysis

BACKGROUND

The rate of improvement in mortality slowed across many high-income countries after 2010. Following the 2007-08 financial crisis, macroeconomic policy was dominated by austerity as countries attempted to address perceived problems of growing state debt and government budget deficits. This study estimates the impact of austerity on mortality trends for 37 high-income countries between 2000 and 2019.

METHODS

We fitted a suite of fixed-effects panel regression models to mortality data (period life expectancy, age-standardised mortality rates (ASMRs), age-stratified mortality rates and lifespan variation). Austerity was measured using the Alesina-Ardagna Fiscal Index (AAFI), Cyclically-Adjusted Primary Balance (CAPB), real indexed Government Expenditure, and Public Social Spending as a % of GDP. Sensitivity analyses varied the lag times, and confined the panel to economic downturns and to non-oil-dominated economies.

RESULTS

Slower improvements, or deteriorations, in life expectancy and mortality trends were seen in the majority of countries, with the worst trends in England & Wales, Estonia, Iceland, Scotland, Slovenia, and the USA, with generally worse trends for females than males. Austerity was implemented across all countries for at least some time when measured by AAFI and CAPB, and for many countries across all four measures (and particularly after 2010). Austerity adversely impacted life expectancy, ASMR, age-specific mortality and lifespan variation trends when measured with Government Expenditure, Public Social Spending and CAPB, but not with AAFI. However, when the dataset was restricted to periods of economic downturn and in economies not dominated hydrocarbon production, all measures of austerity were found to reduce the rate of mortality improvement.

INTERPRETATION

Stalled mortality trends and austerity are widespread phenomena across high-income countries. Austerity is likely to be a cause of stalled mortality trends. Governments should consider alternative economic policy approaches if these harmful population health impacts are to be avoided.

Familiäre Gesundheitsförderung bei Alleinerziehenden und ihren Kindern

Hintergrund

Die Lebenslage von Alleinerziehenden und ihren Kindern geht oft mit besonderen Herausforderungen einher, die in Folge gesundheitliche Beeinträchtigungen mit sich bringen können. Es ist daher von Relevanz, für diese Zielgruppe wirksame Maßnahmen der Gesundheitsförderung zu identifizieren.

Ziel der Arbeit

Die vorliegende Arbeit gibt einen aktuellen Überblick zu Ansätzen der Gesundheitsförderung/Prävention bei Alleinerziehenden und ihren Kindern sowie deren Wirksamkeit.

Methode

Es erfolgte eine systematische Recherche in relevanten Datenbanken mit anschließendem mehrschrittigen Screeningprozess und einer narrativen Ergebnissynthese.

Ergebnisse

Es wurden 27 Studien eingeschlossen, in denen 22 Interventionsprogramme evaluiert wurden. Die Studienlage ist verhaltenspräventiv geprägt, die Evidenzlage ist heterogen. Es zeigen sich eingeschränkte Wirksamkeitsnachweise von Workshop-Formaten, Bildungsangeboten und Kompetenztrainings mit dem Ziel der psychosozialen Ressourcenstärkung bei Alleinerziehenden und ihren Kindern.

Schlussfolgerung

Die Belastbarkeit der Ergebnisse wird durch die mäßige methodische Qualität der Studien relativiert. Durch die Suchstrategie, die auf Studien mit Outcomes für Alleinerziehende fokussiert war, sowie die Methodik des systematischen Reviews wurden fast ausschließlich Angebote der Verhaltensprävention identifiziert. Für verhältnispräventive Interventionen liegen nur selten Studien vor, die explizit Auskunft zur Wirksamkeit bei Alleinerziehenden geben. Das gewählte Vorgehen war somit nur begrenzt in der Lage, das Handlungsfeld umfassend abzubilden. Das Review liefert dennoch einen Baustein eines evidenzbasierten Vorgehens in der Gesundheitsförderung für Alleinerziehende und ihre Kinder.

Poverty, parental work intensity and child emotional and conduct problems

Poverty is known to be associated with poorer child mental wellbeing. Relatedly, the security and quality of employment are reported to affect adult wellbeing. Less is known about how both poverty and parental employment affect children's mental wellbeing. This paper uses nine waves (2005/06-2017/18) of the Growing Up in Scotland (GUS) study to examine how the longitudinal trajectories of poverty and work intensity are associated with the longitudinal trajectories of mental wellbeing in a nationally representative sample of 3994 children (ages 0 to 12). This analysis was conducted via a bivariate multilevel non-linear growth curve model for the widely used Strengths and Difficulties Questionnaire (SDQ) subscales of conduct problems and emotional symptoms. Results show that unstable work intensity and poverty trajectories arising from the 2008 financial crisis are associated with substantial changes in the trajectories of conduct and emotional problems, but with key differences between the individual outcomes: increasing work intensity is associated with around a fifth of a standard deviation increase in conduct problems; decreasing work intensity over time is associated with around a fifth of a standard deviation increase in emotional problems; material deprivation is associated with an increase in both conduct and emotional problems, at around a tenth of a standard deviation; and longitudinal income poverty trajectories are associated with up to around a fifth of a standard deviation increase in conduct problems, but not emotional symptoms. These findings are discussed with the purpose of informing policies to tackle the effects of unstable and/or changing socioeconomic circumstances on children's mental health wellbeing in the context of an economic crisis, as well as its implications for the contemporary socioeconomic landscape and the devastating effects expected of the COVID-19 crisis.

Trends in healthy life expectancy in the age of austerity

BACKGROUND

Worrying changes in life expectancy trends have been observed recently in the UK, largely attributed to austerity policies introduced over the last decade. To incorporate changes to quality, rather than just length of, life, our aim was to describe trends in healthy life expectancy (HLE) for the relevant period.

METHODS

In the absence of available long-term trends, we calculated new estimates of HLE for Scotland for the period 1995-2019, using standard HLE methodologies based on mortality and national survey data, and stratified by sex and socioeconomic deprivation.

RESULTS

Overall, male and female HLE increased markedly between 1995 and 2009, but then decreased by approximately 2 years between 2011 and 2019. A decline was observed for the most and least deprived groups, but this was larger for those living in the 20% most deprived areas, where the decrease was 3.5 years.

CONCLUSIONS

Our findings are further evidence of changing levels of pre-pandemic population health in the UK. An increasing body of UK and international evidence have attributed these changes to UK Government austerity policies. There is an urgent need, therefore, to reverse cuts to social security and protect the income and health of the poorest across all of the UK.

The Intersection of Reproductive, Work-Life Balance and Early-Education and Care Policies: ‘Solo’ Mothers by Choice in the UK and Spain

This article focuses on women who have opted to be mothers on their own by choice in the UK and Spain, and how their access to assisted reproductive technologies in the National Health Service was affected because they were 35 years old or older, forcing them to go to private clinics for their treatment. Having given birth to their children, the participants face a second obstacle: the lack of policies that support work-life balance. A third obstacle also arises, in the form of a lack of childcare and early-education provision, particularly in the UK. The last two obstacles affect the whole population, but they are intensified in the case of solo-mother-families where the mother is responsible for simultaneously being the caregiver and the sole economic provider. Solo motherhood by choice highlights the impact of the absence of these policies, and the inequalities that result from current contemporary conceptualizations of family, woman and early-childhood-care and education. This article draws on ethnographic research that took place in the UK and Spain where I conducted 60 in-depth interviews and participant observations. The aim is to provide an analysis capable of capturing and confronting how inequalities affect women-mothers-workers and their children.

Which is most important for mental health: Money, poverty, or paid work? A fixed-effects analysis of the UK Household Longitudinal Study

BACKGROUND

The relative importance of income, poverty and unemployment status for mental health is unclear, and understanding this has implications for income and welfare policy design. We aimed to assess the association between changes in these exposures and mental health.

METHODS

We measured effects of three transition exposures between waves of the UK Household Longitudinal Study from 2010/11-2019/20 (n=38,697, obs=173,859): income decreases/increases, moving in/out of poverty, and job losses/gains. The outcome was General Health Questionnaire (GHQ), which measures likelihood of common mental disorder (CMD) as a continuous (GHQ-36) and binary measure (score ≥4 = case). We used fixed-effects linear and linear probability models to adjust for time invariant and time-varying confounders. To investigate effect modification, we stratified analyses by age, sex and highest education.

RESULTS

A 10% income decrease/increase was associated with a 0.02% increase (95% CI 0.00, 0.04) and 0.01% reduction (95% CI -0.03, 0.02) in likelihood of CMD respectively. Effect sizes were larger for moving into poverty (+1.8% [0.2, 3.5]), out of poverty (-1.8%, [-3.2, -0.3]), job loss (+15.8%, [13.6, 18.0]) and job gain (-11.4%, [-14.4, -8.4]). The effect of new poverty was greater for women (+2.3% [0.8, 3.9] versus +1.2% [-1.1, 3.5] for men) but the opposite was true for job loss (+17.8% [14.4, 21.2] for men versus +13.5% [9.8, 17.2] for women). There were no clear differences by age, but those with least education experienced the largest effects from poverty transitions, especially moving out of poverty (-2.9%, [-5.7, -0.0]).

CONCLUSIONS

Moving into unemployment was most strongly associated with CMD, with poverty also important but income effects generally much smaller. Men appear most sensitive to employment transitions, but poverty may have larger impacts on women and those with least education. As the COVID-19 pandemic recedes, minimising unemployment as well as poverty is crucial for population mental health.

Effects of social security policy reforms on mental health and inequalities: A systematic review of observational studies in high-income countries

Evidence increasingly shows that changes to social security policies can affect population mental health. Thus, in the context of rising burden of mental illness, it is of major importance to better understand how expansions and contractions to the social security system may impact on mental health of both adults and children. The aim of this systematic review is to provide a synthesis of observational literature on the effects on mental health and inequalities in mental health of social security reforms. We conducted a systematic review of quantitative observational studies of specific national and regional social security policy changes in high-income countries and summarised the mental health effects of these policies. We searched seven electronic databases, including Medline, PsychInfo, Embase, CINAHL, ASSIA (Proquest), Scopus and Research Papers in Economics from January 1979 to June 2020. We included both objective and subjective mental health and wellbeing measures. The study quality was assessed using the Validity Assessment tool for econometric studies. We identified 13,403 original records, thirty-eight of which were included in the final review. Twenty-one studies evaluated expansionary social security policies and seventeen studies evaluated contractionary policies. Overall, we found that policies that improve social security benefit eligibility/generosity are associated with improvements in mental health, as reported by fourteen of the included studies. Social security policies that reduce eligibility/generosity were related to worse mental health, as reported by eleven studies. Ten studies found no effect for either policies contracting or expanding welfare support. Fourteen studies also evaluated the impact on mental health inequalities and found that contractionary policies tend to increase inequalities whereas expansionary policies have the opposite effect. Changes in social security policies can have significant effects on mental health and health inequalities across different recipient groups. Such health effects should be taken into account when designing future social policy reforms.

Changing mortality trends in countries and cities of the UK: a population-based trend analysis

OBJECTIVES

Previously improving life expectancy and all-cause mortality in the UK has stalled since the early 2010s. National analyses have demonstrated changes in mortality rates for most age groups and causes of death, and with deprived populations most affected. The aims here were to establish whether similar changes have occurred across different parts of the UK (countries, cities), and to examine cause-specific trends in more detail.

DESIGN

Population-based trend analysis.

PARTICIPANTS/SETTING

Whole populations of countries and selected cities of the UK.

PRIMARY AND SECONDARY OUTCOME MEASURES

European age-standardised mortality rates (calculated by cause of death, country, city, year (1981-2017), age group, sex and-for all countries and Scottish cities-deprivation quintiles); changes in rates between 5-year periods; summary measures of both relative (relative index of inequality) and absolute (slope index of inequality) inequalities.

RESULTS

Changes in mortality from around 2011/2013 were observed throughout the UK for all adult age groups. For example, all-age female rates decreased by approximately 4%-6% during the 1980s and 1990s, approximately 7%-9% during the 2000s, but by <1% between 2011/2013 and 2015/2017. Equivalent figures for men were 4%-7%, 8%-12% and 1%-3%, respectively. This later period saw increased mortality among the most deprived populations, something observed in all countries and cities analysed, and for most causes of death: absolute and relative inequalities therefore increased. Although similar trends were seen across all parts of the UK, particular issues apply in Scotland, for example, higher and increasing drug-related mortality (with the highest rates observed in Dundee and Glasgow).

CONCLUSIONS

The study presents further evidence of changing mortality in the UK. The timing, geography and socioeconomic gradients associated with the changes appear to support suggestions that they may result, at least in part, from UK Government 'austerity' measures which have disproportionately affected the poorest.

The contribution of changes to tax and social security to stalled life expectancy trends in Scotland: a modelling study

BACKGROUND

Life expectancy (LE) improvements have stalled, and UK tax and welfare 'reforms' have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland.

METHODS

We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms.

RESULTS

We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (-20 weeks), and male LE from 77.6 years to 77.2 years (-23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males.

INTERPRETATION

This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.

Investigating the relationship between changes in social security benefits and mental health: a protocol for a systematic review

INTRODUCTION

Poor mental health is one of the greatest causes of disability in the world. Evidence increasingly shows that population mental health may be influenced by national social security policies. This systematic review aims to establish the relationship between social security and mental health in order to help inform recommendations for policy-makers, practitioners and future research.

METHODS AND ANALYSIS

A systematic review of quantitative observational studies investigating mental health outcomes related to changes in social security policies will be conducted. Six major databases, including Medline, PsychInfo, Embase, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index Abstracts and Scopus, as well as Research Papers in Economics will be searched from January 1979 to April 2020. The electronic database searches will be supplemented by reference and citation searches as well as hand-searching of key journals. The outcomes of interest are objective or subjective mental health outcomes, including stress, anxiety, depression, self-reported mental health scores, subjective well-being and suicide. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the quality of the studies will be assessed by the validity assessment framework designed for appraising econometric studies. A narrative synthesis will be conducted for all included studies. If data permit, study findings will be synthesised by conducting a meta-analysis.

ETHICS AND DISSEMINATION

As it will be a systematic review, without primary data collection, there will be no requirement for ethical approval. Findings will be disseminated through peer-reviewed publications and in various media, for example, conferences or symposia.

PROSPERO REGISTRATION NUMBER

CRD42019154733.

Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled study

BACKGROUND

Universal Credit, a welfare benefit reform in the UK, began to replace six existing benefit schemes in April, 2013, starting with the income-based Job Seekers Allowance. We aimed to determine the effects on mental health of the introduction of Universal Credit.

METHODS

In this longitudinal controlled study, we linked 197 111 observations from 52 187 individuals of working age (16-64 years) in England, Wales, and Scotland who participated in the Understanding Society UK Longitudinal Household Panel Study between 2009 and 2018 with administrative data on the month when Universal Credit was introduced into the area in which each respondent lived. We included participants who had data on employment status, local authority area of residence, psychological distress, and confounding variables. We excluded individuals from Northern Ireland and people out of work with a disability. We used difference-in-differences analysis of this nationally representative, longitudinal, household survey and separated respondents into two groups: unemployed people who were eligible for Universal Credit (intervention group) and people who were not unemployed and therefore would not have generally been eligible for Universal Credit (comparison group). Using the phased roll-out of Universal Credit, we compared the change in psychological distress (self-reported via General Health Questionnaire-12) between the intervention group and the comparison group over time as the reform was introduced in the area in which each respondent lived. We defined clinically significant psychological distress as a score of greater than 3 on the General Health Questionnaire-12. We tested whether there were differential effects across subgroups (age, sex, and education).

FINDINGS

The prevalence of psychological distress increased in the intervention group by 6·57 percentage points (95% CI 1·69-11·42) after the introduction of Universal Credit relative to the comparison group, after accounting for potential confounders. We estimate that between April 29, 2013, and Dec 31, 2018, an additional 63 674 (95% CI 10 042-117 307) unemployed people will have experienced levels of psychological distress that are clinically significant due to the introduction of Universal Credit; 21 760 of these individuals might reach the diagnostic threshold for depression.

INTERPRETATION

Our findings suggest that the introduction of Universal Credit led to an increase in psychological distress, a measure of mental health difficulties, among those affected by the policy. Future changes to government welfare systems should be evaluated not only on a fiscal basis but on their potential to affect health and wellbeing.

FUNDING

Wellcome Trust, UK National Institute for Health Research, and Medical Research Council.

Is austerity responsible for the recent change in mortality trends across high-income nations? A protocol for an observational study

INTRODUCTION

Mortality rates in many high-income countries have changed from their long-term trends since around 2011. This paper sets out a protocol for testing the extent to which economic austerity can explain the variance in recent mortality trends across high-income countries.

METHODS AND ANALYSIS

This is an ecological natural experiment study, which will use regression adjustment to account for differences in exposure, outcomes and confounding. All high-income countries with available data will be included in the sample. The timing of any changes in the trends for four measures of austerity (the Alesina-Ardagna Fiscal Index, real per capita government expenditure, public social spending and the cyclically adjusted primary balance) will be identified and the cumulative difference in exposure to these measures thereafter will be calculated. These will be regressed against the difference in the mean annual change in life expectancy, mortality rates and lifespan variation compared with the previous trends, with an initial lag of 2 years after the identified change point in the exposure measure. The role of underemployment and individual incomes as outcomes in their own right and as mediating any relationship between austerity and mortality will also be considered. Sensitivity analyses varying the lag period to 0 and 5 years, and adjusting for recession, will be undertaken.

ETHICS AND DISSEMINATION

All of the data used for this study are publicly available, aggregated datasets with no individuals identifiable. There is, therefore, no requirement for ethical committee approval for the study. The study will be lodged within the National Health Service research governance system. All results of the study will be published following sharing with partner agencies. No new datasets will be created as part of this work for deposition or curation.

The effect of welfare reform on the health of the unemployed: evidence from a natural experiment in Germany

BACKGROUND

Over the past several decades, governments have enacted far-reaching reforms aimed at reducing the generosity and coverage of welfare benefits. Prior literature suggests that these policy measures may have deleterious effects on the health of populations. In this study, we evaluate the impact of one of the largest welfare reforms in recent history-the 2005 Hartz IV reform in Germany-with a focus on estimating its effect on the health of the unemployed.

METHODS

We employed a quasi-experimental difference-in-differences (DID) design using population-based data from the German Socio-Economic Panel Study, covering the period between 1994 and 2016. We applied DID linear probability modelling to examine the association between the Hartz IV reform and poor self-rated health, adjusting for a range of demographic and socioeconomic confounders.

RESULTS

The Hartz IV reform was associated with a 3.6 (95% CI 0.9 to 6.2) percentage point increase in the prevalence of poor self-rated health among unemployed persons affected by the reform relative to similar but unaffected controls. This negative association appeared immediately following the implementation of the reform and has persisted over time.

CONCLUSION

Governments in numerous European and North American jurisdictions have introduced measures to further diminish the generosity and coverage of welfare benefits. In line with growing concerns over the potential consequences of austerity and associated policy measures, our findings suggest that these reform efforts pose a threat to the health of socioeconomically disadvantaged populations.

How Did Employment and Financial Strain Affect the Self-rated Health of Lone Mothers Around the Time of the Economic Crisis? A Cross-sectional Comparison of the United Kingdom and Sweden

Lone mothers face higher risk of poor self-rated health (SRH) than coupled mothers, partly explained by financial strain, non-employment, and welfare context. Comparing the United Kingdom and Sweden, we sought to determine how the economic crisis of 2008 affected the inequality in lone and coupled mothers SRH and what socioeconomic factors impacted this. Survey data was divided into periods corresponding to before, during, and after the economic crisis. Logistic regression was used to evaluate the impact of socioeconomic factors. Financial strain explained 70%–80% of the excess risk for poor health among Swedish lone mothers and 40% of those in the United Kingdom. Controlling for background and socioeconomic factors eliminated the health inequality among Swedish mothers. In the United Kingdom this inequality remained and may reflect the impact of social mechanisms such as stigma. Converse to what was expected, we did not observe significant variation over time in factors affecting SRH, nor did we find conclusive evidence of the impact of the economic crisis on the SRH of lone mothers. Factors that may account for these counterintuitive results, including retrenchment of the Swedish welfare state, economic lag, and reduction in overall inequality in health, are discussed.

Trends in gender and socioeconomic inequalities in mental health following the Great Recession and subsequent austerity policies: a repeat cross-sectional analysis of the Health Surveys for England

OBJECTIVE

It is known that mental health deteriorated following the 2008 global financial crisis, and that subsequent UK austerity policies post-2010 disproportionately impacted women and those in deprived areas. We aimed to assess whether gender and socioeconomic inequalities in poor mental health have changed since the onset of austerity policies.

DESIGN

Repeat cross-sectional analysis of survey data.

SETTING

England.

PARTICIPANTS

Nationally and regionally representative samples of the working-age population (25-64 years) from the Health Survey for England (1991-2014).

OUTCOME MEASURES

Population-level poor mental health was measured by General Health Questionnaire-12 (GHQ) caseness, stratified by gender and socioeconomic position (area-level deprivation and highest educational attainment).

RESULTS

The prevalence of age-adjusted male GHQ caseness increased by 5.9% (95% CI 3.2% to 8.5%, p<0.001) from 2008 to 2009 in the immediate postrecession period, but recovered to prerecession levels after 2010. In women, there was little change in 2009 or 2010, but an increase of 3.0% (95% CI 1.0% to 5.1%, p=0.004) in 2012 compared with 2008 following the onset of austerity. Estimates were largely unchanged after further adjustment for socioeconomic position, employment status and household income as potential mediators. Relative socioeconomic inequalities in GHQ caseness narrowed from 2008 to 2010 immediately following the recession, with Relative Index of Inequality falling from 2.28 (95% CI 1.89 to 2.76, p<0.001) to 1.85 (95% CI 1.43 to 2.38, p<0.001), but returned to prerecession levels during austerity.

CONCLUSIONS

Gender inequalities in poor mental health narrowed following the Great Recession but widened during austerity, creating the widest gender gap since 1994. Socioeconomic inequalities in poor mental health narrowed immediately postrecession, but this trend may now be reversing. Austerity policies could contribute to widening mental health inequalities.