Explaining mental health inequalities in Northern Sweden: a decomposition analysis

The Effect of Social Determinants of Health on Psychological Health Among Older Adults in Ghana

This study examines the effects of various factors, including socioeconomic status, built environment, access to healthcare, educational level, social participation, and economic stability, on older adults' psychological health. The current study analyzed a nationally representative sub-sample of 2,577 respondents aged 50 and above from the World Health Organization's Study on Global AGEing and Adult Health (WHO SAGE) Wave 2. WHO SAGE Wave 2 is cross-sectional data collected via in-person structured interviews. Ordinal least square (OLS) was used to measure the average effect of social determinants of health (SDoH), and quantile regression analysis was used to determine the effects of SDoH on older adults' psychological health at different quantiles, specifically 10th, 50th, and 90th percentiles. Significant determinants of psychological health across all quantiles included age, healthcare access, marital status, economic stability, and neighborhood and built environment. However, the degrees of significance for residence, gender, educational level, chronic diseases, and social participation varied between quantiles, showing differing effects on older adults with high or low psychological health. Religion was insignificant across all quantiles. This study highlights the need for governments and public health agencies to develop targeted interventions and strategies that support the psychological well-being of older adults in the country.

Social Vulnerability and Prevalence and Treatment for Mental Health and Substance Use Disorders

Importance

Community-level social vulnerability (SV) is associated with physical illness and premature mortality. Its association with mental health (MH) and substance use disorders (SUDs) needs further study.

Objective

To study associations of SV with clinical diagnoses of MH disorders, SUDs, and related treatments in the US noninstitutionalized population of adults aged 18 years and older.

Design, Setting, and Participants

A survey of adults in a national sample of US households between October 2020 and October 2022. Participants drawn from a multistage, clustered, and stratified area probability sample of US households were included, excluding adults older than 65 years because of the difficulty of differentiating mental disorders from symptoms of dementia. The sample also included adults living in prisons, state psychiatric hospitals, and homeless shelters who were excluded from the sample of US households used in these analyses. Each sample household was sent a letter explaining the study and offering the option to complete the household roster online, by phone, or by email. Of the 12 906 adults selected for clinical interviewing in the household sample, 4674 completed clinical interviews.

Main Outcomes and Measures

Main outcomes were Structured Clinical Interview for DSM-5 past-year diagnoses of MH disorders and SUDs and responses to survey questions regarding treatment received. The Social Vulnerability Metric (SVM) and the Area Deprivation Index (ADI) were used to determine SV at the residential zip code level.

Results

The analysis involved 4674 participants (2904 [62.13%] female and 1770 [37.87%] male; mean [SD] age, 41.51 [13.41] years). Controlling for measured confounders, the SVM was significantly associated with diagnoses of schizophrenia spectrum disorder (SSD; adjusted odds ratio [aOR], 17.22; 95% CI, 3.05-97.29), opioid use disorder (OUD; aOR, 9.47; 95% CI, 2.30-39.02), stimulant use disorder (aOR, 6.60; 95% CI, 2.01-21.67), bipolar I disorder (aOR, 2.39; 95% CI, 1.19-4.80), posttraumatic stress disorder (aOR, 1.63; 95% CI, 1.06-2.50), and any MH disorder (aOR, 1.44; 95% CI, 1.14-1.83), but not major depressive disorder (MDD), generalized anxiety disorder (GAD), or any SUD. Results were similar for the ADI but generally of lower magnitude (SSD aOR, 11.38; 95% CI, 1.61-80.58; OUD aOR, 2.05; 95% CI, 0.30-14.10; stimulant use disorder aOR, 2.18; 95% CI, 0.52-9.18). Among participants with SSDs, SV was associated with reduced MH treatment (aOR, 0.001; 95% CI, 0.00-0.18) and reduced SUD treatment in participants with OUD or stimulant use disorder (aOR, 0.24; 95% CI, 0.02-2.80).

Conclusions and Relevance

In contrast to previous studies using nonclinical symptom-based survey data, we found no association between SV and GAD or MDD. By contrast, there were associations of SV with prevalence of SSD, stimulant use disorder, and OUD with corresponding decreases in treatment. These results suggest that the SVM might assist in developing more comprehensive care models that integrate medical and social care for MH disorders and SUDs.

Exploring sex variations in the incidence of cardiovascular events: a counterfactual decomposition analysis

BACKGROUND

Some cardiovascular risk factors (CVRFs) that occur differently in men and women can be addressed to reduce the risk of suffering a major adverse cardiovascular event (MACE). Furthermore, the development of MACE is highly influenced by social determinants of health. Counterfactual decomposition analysis is a new methodology that has the potential to be used to disentangle the role of different factors in health inequalities. This study aimed to assess sex differences in the incidence of MACE and to estimate how much of the difference could be attributed to the prevalence of diabetes, hypertension, hypercholesterolaemia and socioeconomic status (SES).

METHODS

Descriptive and counterfactual analyses were conducted in a population of 278 515 people with CVRFs. The contribution of the causal factors was estimated by comparing the observed risk ratio with the causal factor distribution that would have been observed if men had been set to have the same factor distribution as women. The study period was between 2018 and 2021.

RESULTS

The most prevalent CVRF was hypercholesterolaemia, which was similar in both sexes, while diabetes was more prevalent in men. The incidence of MACE was higher in men than in women. The main causal mediating factors that contributed to the sex differences were diabetes and SES, the latter with an offsetting effect.

CONCLUSIONS

This result suggests that to reduce the MACE gap between sexes, diabetes prevention programmes targeting men and more gender-equal salary policies should be implemented.

Evaluating the impact of the Community Helpers Program on adolescents 12-18 years old in Edmonton, Canada

INTERVENTION

Alberta Health Services (AHS) Community Helpers Program (CHP) to enhance mental health among youth.

RESEARCH QUESTION

Identifying the impact of CHP on mental illness-related acute care use among adolescents aged 12-18 years in Edmonton and determining cost avoidance.

METHODS

Using administrative data from AHS, public school catchment area data from the Edmonton Public School Board, and area-level socioeconomic deprivation status indicators from the Pampalon deprivation index, we applied geographical regression discontinuity design to estimate the effect of CHP implementation on depression-, anxiety-, and suicide-related acute care use (emergency department visits and inpatient admissions). Cost data were derived from Interactive Health Data Application of Alberta Health. The study period (2002-2022) included pre (2002-2011) and post (2012-2020) CHP implementation periods.

RESULTS

CHP had statistically significant impact when distance from the boundary (catchment area identifier to divide the sample into treated and control groups) was between 600 and 800 m. About 90 and 80 fewer anxiety- and depression-related visits (per 1000 visits) were observed among individuals aged 12-15 and 16-18 years, respectively, in catchment areas of the public schools where CHP was implemented. Impact of CHP on suicide-related visits was only statistically significant among individuals aged 12-15 years. Annual cost reduction ranged from $161,117 to $269,255 for anxiety- and depression-related visits.

CONCLUSION

Findings show contextual effect of CHP; i.e., being potentially exposed to the program reduced the likelihood of anxiety- and depression-related visits. Costs of CHP implementation could be compared with the avoided costs to assess economic benefits of implementing CHP.

Socio-economic and spatial inequalities in animal sources of iron-rich foods consumption among children 6-23 months old in Ethiopia: A decomposition analysis

Iron deficiency anaemia is the most common type of anaemia in young children which can lead to long-term health consequences such as reduced immunity, impaired cognitive development, and school performance. As children experience rapid growth, they require a greater supply of iron from iron-rich foods to support their development. In addition to the low consumption of iron-rich foods in low- and lower-middle-income countries, there are also regional and socio-economic disparities. This study aimed to assess contributing factors of wealth-related inequality and geographic variations in animal sources of iron-rich food consumption among children aged 6-23 months in Ethiopia. We used data from the Ethiopian Mini Demographic and Health Surveys (EMDHS) 2019, a national survey conducted using stratified sampling techniques. A total of 1,461 children of age 6-23 months were included in the study. Iron-rich animal sources of food consumption were regarded when parents/caregivers reported that a child took at least one of the four food items identified as iron-rich food: 1) eggs, 2) meat (beef, lamb, goat, or chicken), 3) fresh or dried fish or shellfish, and 4) organs meat such as heart or liver. Concentration indices and curves were used to assess wealth-related inequalities. A Wagstaff decomposition analysis was applied to identify the contributing factors for wealth-related inequality of iron-rich animal source foods consumption. We estimated the elasticity of wealth-related inequality for a percentage change in socioeconomic variables. A spatial analysis was then used to map the significant cluster areas of iron-rich animal source food consumption among children in Ethiopia. The proportion of children who were given iron-rich animal-source foods in Ethiopia is 24.2% (95% CI: 22.1%, 26.5%), with figures ranging from 0.3% in Dire Dawa to 37.8% in the Oromia region. Children in poor households disproportionately consume less iron-rich animal-source foods than those in wealthy households, leading to a pro-rich wealth concentration index (C) = 0.25 (95% CI: 0.12, 0.37). The decomposition model explained approximately 70% of the estimated socio-economic inequality. About 21% of the wealth-related inequalities in iron-rich animal source food consumption in children can be explained by having primary or above education status of women. Mother's antenatal care (ANC) visits (14.6%), living in the large central and metropolitan regions (12%), household wealth index (10%), and being in the older age group (12-23 months) (2.4%) also contribute to the wealth-related inequalities. Regions such as Afar, Eastern parts of Amhara, and Somali were geographic clusters with low iron-rich animal source food consumption. There is a low level of iron-rich animal source food consumption among children, and it is disproportionately concentrated in the rich households (pro-rich distribution) in Ethiopia. Maternal educational status, having ANC visits, children being in the older age group (12-23 months), and living in large central and metropolitan regions were significant contributors to these wealth-related inequalities in iron-rich animal source foods consumption. Certain parts of Ethiopia such as, Afar, Eastern parts of Amhara, and Somali should be considered priority areas for nutritional interventions to increase children's iron-rich animal source foods consumption.

Association of medication clusters and subsequent labor market marginalization in refugee and Swedish-born young adults with common mental disorders in Sweden

Little is known about the association between common mental disorders (CMD) and labor market integration among refugee and Swedish-born young adults. Socially disadvantaged patients such as refugees are more likely to discontinue their medication use prematurely. This study aimed to identify clusters of individuals with similar psychotropic medication patterns; and examine the relationship between cluster membership with labor market marginalization (LMM) in refugee and Swedish-born young adults with CMD. The study uses a longitudinal matched cohort aged 18-24 years with CMD diagnoses from Swedish registers covering 2006-2016. Dispensed psychotropic medications (antidepressants, antipsychotics, anxiolytics, sedative-hypnotics, mood stabilizers) were collected one year before and after CMD diagnosis. Clusters of patients with similar time courses of prescribed dosages were algorithmically identified. The association of cluster membership with subsequent LMM, (long-term sickness absence, SA, disability pension, DP, or long-term unemployment, UE) was assessed using Cox regression. Among 12,472 young adults with CMD, there were 13.9% with SA, 11.9% with DP, and 13.0% with UE during a mean follow-up of 4.1 years (SD 2.3 years). Six clusters of individuals were identified. A cluster with a sustained increase in all medication types yielded the highest hazard ratio (HR [95% CI]) 1.69 [1.34, 2.13] for SA and 2.63 [2.05, 3.38] for DP. The highest HRs of UE give a cluster with a concentrated peak in antidepressants at CMD diagnosis (HR 1.61[1.18, 2.18]). Refugees and Swedish-born showed similar associations between clusters and LMM. To prevent LMM, targeted support and early assessment of CMD treatment are needed for individuals with a sustained increase in psychotropic medication after CMD diagnosis and for refugees in high-risk clusters for UE characterized by a rapid lowering of treatment dosages, which could be an indicator for premature medication discontinuation.

Social Determinants of Health: An Overview for the Primary Care Provider

Social determinants of health (SDoH) are reflected in how people live (access to health care, economic stability, built environment, food security, climate), learn (the educational environment), work (occupational environment), and play/socialize (social context and digital domain). All of these day-to-day conditions play a vital role in a patient's overall health, and a primary care provider should be prepared to understand their role to screen, assess, and address SDoH in clinical practice.

The Impact of Household Debt on the Health of the Elderly in China: Evidence from China Family Panel Studies

With the aging of China's population and the expansion of household debt, the health of the elderly has become an important social issue. Based on the 2018 China Family Panel Studies (CFPS) database, we explored the impact of household debt on the health of older adults and the mechanism of transmission. The Oprobit and IV-Oprobit models were employed for our analysis. Results: (1) Household debt had a significant negative impact on both the physical and mental health of older adults. (2) Female older adults were more sensitive to the impact of household debt. Additionally, a higher education level led to an increasing impact of debt on mental health, but physical health was only affected in the low-education group. (3) The impact of household debt had an inverted U-shape relationship with household income, indicating that, as household income increases, the impact on health level first rises and then reduces after peaking at a middling level of income. (4) According to the mechanism analysis, household debt affects the health of the elderly by causing them to return to work and reducing their medical expenditures. Considering the above conclusions, we put forward some policy implications to alleviate the health problems of the elderly.

Contributing risk factors of common psychiatric disorders in the Pakistani population

With an increasing incidence of psychiatric disorders worldwide, there is a need for a better understanding of the population-specific contributing risk factors that are associated with common psychiatric conditions. This study aimed to assess the correlation between socioeconomic, environmental and clinical features associated with major depression (MDD n = 479), bipolar disorder (BD n = 222) and schizophrenia (SHZ n = 146), in the Pakistani population. Multinomial logistic regression and Pearson's correlation were applied to assess the association and correlation between demographic, socioeconomic, environmental, and clinical features of MDD, BD and SHZ. In the present study, MDD was found to be more prevalent than BD and SHZ. The average age at onset (AAO), was observed to be earlier in females with BD and SHZ, in addition, females with a positive family history of MDD, BD and SHZ also had an earlier AAO. The fitted multinomial logistic regression model indicated a significant association of; aggression, tobacco use, drugs abuse, history of head injuries and family history with BD as compared to MDD, while insomnia and suicidality were significantly associated with MDD. Strong positive correlations were observed mainly between age/AAO, AAO/tobacco use and aggression/insomnia in all three cohorts. In conclusion, the present study identifies possible contributing socio-demographic, biological and environmental factors that are correlated and associated with the psychiatric conditions in the Pakistani population.

Lifestyle, Demographic and Socio-Economic Determinants of Mental Health Disorders of Employees in the European Countries

Ensuring the health and well-being of workers should be a top priority for employers and governments. The aim of the article is to evaluate and rank the importance of mental health determinants: lifestyle, demographic factors and socio-economic status. The research study is based on EHIS 2013-2015 data for a sample of N = 140,791 employees from 30 European countries. The results obtained using machine learning techniques such as gradient-boosted trees and SHAPley values show that the mental health of European employees is strongly determined by the BMI, age and social support from close people. The next vital features are alcohol consumption, an unmet need for health care and sports activity, followed by the affordability of medicine or treatment, income and occupation. The wide range of variables clearly indicates that there is an important role for governments to play in order to minimize the risk of mental disorders across various socio-economic groups. It is also a signal for businesses to help boost the mental health of their employees by creating holistic, mentally friendly working conditions, such as offering time-management training, implementing morning briefings, offering quiet areas, making employees feel valued, educating them about depression and burnout symptoms, and promoting a healthy lifestyle.

Stigma towards people with mental illness in the Nordic countries - a scoping review

INTRODUCTION

Stigma affects people with mental illness globally, however, it is proposed that stigma is less prevalent in wealthier countries and that people hold more positive attitudes in Northern and Western Europe. Even so, accounts from surveys in Denmark and Sweden reveal that stigma is very much prevalent.

AIM

This scoping review aims to shed light on the body of literature regarding mental-health-related stigma in the Nordic Countries and identify knowledge gaps.

METHODS

We searched four electronic databases in December 2017 and again in June 2020. All types of empirical studies (qualitative, quantitative, and mix-methods) examining the stigma of people with mental illness were included.

RESULTS

In total, 61 studies were included. Overall, findings from the Nordic countries resemble global findings. Studies are primarily descriptive, and mostly survey studies of attitudes toward people with mental illness in the general population. Few studies focus on discrimination, and those who do, measure intended behavior in hypothetical situations rather than actual acts of discrimination in real-life situations. Studies were mostly conducted on a community or organizational level; no studies were identified on a system level. Experienced stigma and discrimination by patients, but also relatives, were a focus in one-third of the studies. Very few studies of interventions to reduce stigma and discrimination were identified.

CONCLUSION

More studies into stigma on a system or institutional level are needed. Ways to measure acts of discrimination should be invented. Furthermore, interventions to reduce stigma and discrimination should be developed, targeting all levels of society.

Determinants of Inadequate Minimum Dietary Diversity Intake Among Children Aged 6-23 Months in Sub-Saharan Africa: Pooled Prevalence and Multilevel Analysis of Demographic and Health Survey in 33 Sub-Saharan African Countries

Background

Inappropriate feeding practices result in significant threats to child health by impaired cognitive development, compromised educational achievement, and low economic productivity, which becomes difficult to reverse later in life. There is minimal evidence that shows the burden and determining factors of inadequate dietary intake among children aged under 2 years in sub-Saharan African (SSA) countries. Therefore, this study aimed to assess the pooled magnitude, wealth-related inequalities, and other determinants of inadequate minimum dietary diversity (MDD) intake among children aged 6-23 months in the SSA countries using the recent 2010-2020 DHS data.

Methods

A total of 77,887 weighted samples from Demographic and Health Survey datasets of the SSA countries were used for this study. The Microsoft Excel and STATA version 16 software were used to clean, extract, and analyze the data. A multilevel binary logistic regression model was fitted. The concentration index and curve were applied to examine wealth-related inequalities in the outcomes. P-value < 0.05 with 95% CI was taken to declare statistical significance.

Results

The pooled magnitude of inadequate MDD intake among children aged 6-23 months in SSA was 76.53% (95% CI: 73.37, 79.70), ranging from 50.5% in South Africa to 94.40% in Burkina Faso. Individual-level factors such as women having secondary and above education (AOR = 0.66; 95% CI; 0.62, 0.70), being employed (AOR = 0.76; 95% CI; 0.72, 0.79), having household media exposure (AOR = 0.69; 95% CI; 0.66, 0.72), richest wealth (AOR = 0.46; 95% CI; 0.43, 0.50), having health institution delivery (AOR = 0.87;95% CI; 0.83, 0.91), and community-level factor such as living in upper middle-income country (AOR = 0.42; 95% CI; 0.38, 0.46) had a significant protective association, whereas rural residence (AOR = 1.29; 95% CI; 1.23, 1.36) has a significant positive association with inadequate MDD intake among children aged 6-23 months. Inadequate MDD intake among children aged 6-23 months in SSA was disproportionately concentrated on the poor households (pro-poor) (C = -0.24; 95% CI: -0.22, -0.0.26).

Conclusion and Recommendations

There is a high magnitude of inadequate minimum dietary diversity intake among children aged 6-23 months in SSA. Variables such as secondary and above maternal education, having an employed mother, having exposure to media, richest wealth, having health institution delivery, and living in the upper middle-income country have a significant negative association, whereas living in rural residence has a significant positive association with inadequate MDD intake. These findings highlight that to increase the MDD intake in the region, policy makers and other stakeholders need to give prior attention to enhancing household wealth status, empowering women, and media exposure.

Does socioeconomic inequality exist in minimum acceptable diet intake among children aged 6-23 months in sub-Saharan Africa? Evidence from 33 sub-Saharan African countries' demographic and health surveys from 2010 to 2020

Background

Child undernutrition is a major public health problem in many resource-poor communities in the world. More than two-thirds of malnutrition-related child deaths are associated with inappropriate feeding practices during the first 2 years of life. Socioeconomic inequalities are one of the most immediate determinants. Though sub-Saharan Africa (SSA) shares the huge burden of children undernutrition, as to our search of literature there is limited evidence on the pooled magnitude, socioeconomic inequalities of minimum acceptable diet intake and its contributing factors among children aged 6 to 23 months in the region. This study aimed to assess the level of socio-economic inequalities of minimum acceptable diet intake, and its contributor factors among children aged 6–23 months in SSA using recent 2010–2020 DHS data.

Methods

A total of 78,542 weighted samples from Demographic and Health Survey datasets of SSA countries were used for this study. The data were cleaned using MS excel and extracted and analyzed using STATA V.16 software. The concentration index and curve and wag staff type decomposition analysis were applied to examine wealth-related inequalities in the outcomes. P-value < 0.05 was taken to declare statistical significance.

Results

The pooled magnitude of MAD intake among children age 6–23 months in SSA was 9.89% [95%CI: 8.57, 11.21%] ranging from 3.10% in Guinea to 20.40% in Kenya. MAD intake in SSA was disproportionately concentrated on the rich households (pro-rich) [C = 0.191; 95% CI: 0.189, 0.193]. Residence (36.17%), media exposure (23.93%), and women’s education (11.63%) explained the pro-rich inequalities in MAD intake. The model explained 55.55% of the estimated socioeconomic inequality in MAD intake in SSA.

Conclusion and recommendations

Minimum acceptable diet intake in SSA is relatively low. There are moderate socioeconomic inequalities in MAD intake in SSA, mainly explained by residence, media exposure and women’s education. The government of sub-Saharan African countries should plan and work in short terms through the program that endorses women empowerment such as income generation, cash assistance for mothers who have under 2 years of children and women employment using affirmative actions, and nutrition education such as media campaigns and promoting breast feedings. Long-term plans are also needed for those SSA countries with lower income status through programs to enhance their country’s economy to the middle and higher economic level and to improve the wealth index of individual households to narrow the poor-rich gap in the minimum acceptable diet intake.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00521-y.

Decomposing socio-economic inequality in vaccination coverage among Pakistani children: A population-based cross-sectional study

There is scarce knowledge about factors contributing to underlying inequalities in vaccination coverage among Pakistani children. Therefore, the main objective of this study is to measure and decompose socioeconomic inequalities in childhood vaccination coverage. Pakistan Demographic and Health Survey, version 2017-18, data were used for analysis. Bivariate association was checked through Chi-square test and concentration curve (CC) and concentration index (CI) were used to assess the existence and nature of inequality. Finally, decomposition analysis was performed to measure the contribution of different factors to the observed inequality. Our findings suggested that vaccination coverage is more concentrated among children of educated mothers (CI = 0.296) and decomposition results suggest that a substantial proportion of the inequality is explained by maternal education, wealth status, paternal education and improved sanitation (34%, 19%, 14% and 21% respectively). Also, differences are observed between regions regarding vaccination coverage. There is need of female-targeted interventions to increase maternal role in the society through better education and decision-making autonomy. Also, the policies to improve the household's wealth status should be considered.

Health in Conflict Zones: Analyzing Inequalities in Mental Health in Colombian Conflict-Affected Territories

Objectives: Colombia’s civil conflict and persistent socio-economic disparities have contributed to mental health inequalities in conflict-affected territories. We explore the magnitude of mental health inequalities, contributing socio-economic factors, and sociodemographic characteristics that explain these differences.

Methods: The study draws on data collected in 2018, using the household survey Conflicto, Paz y Salud (CONPAS) applied to 1,309 households in Meta, Colombia. Logistic regression and decomposition analysis were used to analyze the risk of mental health disorders, measured with the Self-Reporting Questionnaire -20 (SRQ-20).

Results: Individuals with lower socio-economic status are at a higher risk for mental health disorders. Forced displacement accounts for 31% of the measured mental health inequalities. Disparities in employment, education level, disability and conflict incidence between municipalities are other contributing factors. Women and people with disabilities are respectively 2.3 and 1.2 times more prone to present a mental health disorder.

Conclusion: It is necessary to tackle the identified risk factors and sociodemographic circumstances that contribute to mental health inequalities in conflict-affected territories, as these hinder adequate/equitable access to mental health services.

Decomposition of inequalities in out-of-pocket health expenditure burden in Saudi Arabia

Out-of-pocket (OOP) health expenditure remains a serious welfare problem worldwide. The aim of this study was to investigate and decompose factors that are associated with inequalities in relative OOP health expenditure, estimated as the percentage of income spent on healthcare, in Saudi Arabia. Data from 10,785 respondents were obtained from a national cross-sectional survey conducted in Saudi Arabia as a part of the 2018 Family Health Survey. Inequalities in relative OOP health expenditure were measured using concentration indices and concentration curves. Moreover, the Wagstaff approach was used to decompose the concentration index of relative OOP health expenditure to assess the contribution of each of its determinants. The results revealed that relative OOP health expenditure in Saudi Arabia are concentrated among the poor (concentration index = -0.151, p < 0.01), resulting in a greater burden for the poor. Decomposition of the factors that contribute to this inequality revealed heterogeneity. Specifically, factors that increase the burden amongst the poor included aged above 60 years, and low levels of education, whereas factors that increase the burden amongst the rich included male gender, below the age of 60 years, secondary and higher education, having health insurance coverage, and suffering from chronic illnesses. Importantly, these results demonstrate that poor people might be exposed to hazardous health spending. Therefore, efforts to curbing OOP health expenditure should be framed by taking into account the specific factors that drive the burden towards the poor, such as older age and lack of education, so as to safeguard the overall welfare of the poor.

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

Intersectionality has recently gained traction in health inequality research emphasizing multiple intersecting dimensions of inequality as opposed to the traditional unidimensional approaches. In this study inequalities in mental health were estimated across intersections of gender, income, education, occupation, country of birth, and sexual orientation. The outcomes and inequalities of intersectional strata were disentangled analogously to the possibilities described by intersectionality theory; as a result of either of the two inequality dimensions, as a result of the sum the dimensions, or as a unique outcome not equaling the sum. Furthermore the study examined the discriminatory accuracy of the six inequality dimensions as well as the intersectional space comprising 64 strata. The study population (N = 52,743) consists of a yearly random sample of the Swedish population 26-84 years between 2010 and 2015, from The Health on Equal Terms survey. Mental health was measured through a self-administered General Health Questionnaire (GHQ)-12, and sociodemographics through survey and linked register data. Intersectional inequalities in mental health were estimated for all pairwise combinations of inequality dimensions by joint inequalities, excess intersectional inequalities and referent inequalities. The findings of the study found that the sum of dimensions contributed to the overall (joint) inequality in mental health rather than a reinforced adverse effect of multiple disadvantages or the contribution by a single dimension. Nevertheless, the dimension of income was found to be the most important in terms of relative contribution. The discriminatory accuracy was low indicating that policy action targeting mental health should be universal rather than focusing on particular groups. The results highlight the unpredictable inequality patterns revealed by an intersectional approach, even for a single health outcome and within one country, and illustrate the need for empirical investigations into the actual population patterns in health that appear in the intersections of multiple disadvantages.

Socioeconomic inequalities in hypertension in Kenya: a decomposition analysis of 2015 Kenya STEPwise survey on non-communicable diseases risk factors

BACKGROUND

One in four Kenyans aged 18-69 years have raised blood pressure. Despite this high prevalence of hypertension and known association between socioeconomic status and hypertension, there is limited understanding of factors explaining inequalities in raised blood pressure in Kenya. Hence, we quantified the socioeconomic inequality in hypertension in Kenya and decomposed the determinants contributing to such inequality.

METHODS

We used data from the 2015 Kenya STEPwise survey for non-communicable diseases risk factors. We included 4422 respondents aged 18-69 years. We estimated the socioeconomic inequality using the concentration index (C) and decomposed the C using Wagstaff decomposition analysis.

RESULTS

The overall concentration index of hypertension in Kenya was - 0.08 (95% CI: - 0.14, - 0.02; p = 0.005), showing socioeconomic inequalities in hypertension disfavouring the poor population. About half (47.1%) of the pro-rich inequalities in hypertension was explained by body mass index while 26.7% by socioeconomic factors (wealth index (10.4%), education (9.3%) and paid employment (7.0%)) and 17.6% by sociodemographic factors (female gender (10.5%), age (4.3%) and marital status (0.6%)). Regional differences explained 7.1% of the estimated inequality with the Central region alone explaining 6.0% of the observed inequality. Our model explained 99.7% of the estimated socioeconomic inequality in hypertension in Kenya with a small non-explained part of the inequality (- 0.0002).

CONCLUSION

The present study shows substantial socioeconomic inequalities in hypertension in Kenya, mainly explained by metabolic risk factors (body mass index), individual health behaviours, and socioeconomic factors. Kenya needs gender- and equity-focused interventions to curb the rising burden of hypertension and inequalities in hypertension.

Inequalities in child health care in Pakistan: measurement and decomposition analysis of maternal educational impact

OBJECTIVES

The aim of the study was to measure the impact of maternal education on inequalities in child health care and to explore the contribution of different factors to the observed inequality.

STUDY DESIGN

The study is based on secondary data from the Pakistan Demographic and Health Survey 2017-18.

METHODS

Concentration curves and indices were used to identify and quantify the inequality in child health care. Moreover, contributions of different factors to the observed inequality were investigated using decomposition analysis.

RESULTS

The concentration indices for health care provided were 0.078 (P < 0.001) when a child was experiencing diarrhoea and 0.088 (P < 0.001) for fever/cough. The results of this study indicate that healthcare practices are more common among children of educated mothers. The main contributors resulting in the observed inequalities in child health care were improved sanitation (about 6% for diarrhoea and 15% for fever/cough treatment), rural residence (about 4% and 23% for diarrhoea and fever/cough treatment, respectively), wealth status (49% and 28% for diarrhoea and fever/cough treatment, respectively) and maternal education (26% for diarrhoea and 28% for fever/cough treatment).

CONCLUSION

The findings suggested that child health care is more frequently provided among educated mothers; therefore, steps should be taken to improve maternal education. Moreover, policies should seek to increase/improve the roles of women in society, as well as job opportunities to overcome the financial barriers of healthcare provision.

Decomposing socioeconomic inequality in poor mental health among Iranian adult population: results from the PERSIAN cohort study

BACKGROUND

Socioeconomic inequality in mental health in Iran is poorly understood. This study aimed to assess socioeconomic inequality in poor mental health among Iranian adults.

METHODS

The study used the baseline data of PERSIAN cohort study including 131,813 participants from 17 geographically distinct areas of Iran. The Erreygers Concentration index (E) was used to quantify the socioeconomic inequalities in poor mental health. Moreover, we decomposed the E to identify factors contributing to the observed socioeconomic inequality in poor mental health in Iran.

RESULTS

The estimated E for poor mental health was - 0.012 (95% CI: - 0.0144, - 0.0089), indicating slightly higher concentration of mental health problem among socioeconomically disadvantaged adults in Iran. Socioeconomic inequality in poor mental health was mainly explained by gender (19.93%) and age (12.70%). Region, SES itself, and physical activity were other important factors that contributed to the concentration of poor mental health among adults with low socioeconomic status.

CONCLUSION

There exists nearly equitable distribution in poor mental health among Iranian adults, but with important variations by gender, SES, and geography. These results suggested that interventional programs in Iran should focus on should focus more on socioeconomically disadvantaged people as a whole, with particular attention to the needs of women and those living in more socially disadvantaged regions.

Improving the Health of Individuals With Cerebral Palsy: Protocol for the Multidisciplinary Research Program MOVING ON WITH CP

Background

Cerebral palsy (CP) is one of the most common early onset disabilities globally. The causative brain damage in CP is nonprogressive, yet secondary conditions develop and worsen over time. Individuals with CP in Sweden and most of the Nordic countries are systematically followed in the national registry and follow-up program entitled the Cerebral Palsy Follow-Up Program (CPUP). CPUP has improved certain aspects of health care for individuals with CP and strengthened collaboration among professionals. However, there are still issues to resolve regarding health care for this specific population.

Objective

The overall objectives of the research program MOVING ON WITH CP are to (1) improve the health care processes and delivery models; (2) develop, implement, and evaluate real-life solutions for Swedish health care provision; and (3) evaluate existing health care and social insurance benefit programs and processes in the context of CP.

Methods

MOVING ON WITH CP comprises 9 projects within 3 themes. Evaluation of Existing Health Care (Theme A) consists of registry studies where data from CPUP will be merged with national official health databases, complemented by survey and interview data. In Equality in Health Care and Social Insurance (Theme B), mixed methods studies and registry studies will be complemented with focus group interviews to inform the development of new processes to apply for benefits. In New Solutions and Processes in Health Care Provision (Theme C), an eHealth (electronic health) procedure will be developed and tested to facilitate access to specialized health care, and equipment that improves the assessment of movement activity in individuals with CP will be developed.

Results

The individual projects are currently being planned and will begin shortly. Feedback from users has been integrated. Ethics board approvals have been obtained.

Conclusions

In this 6-year multidisciplinary program, professionals from the fields of medicine, social sciences, health sciences, and engineering, in collaboration with individuals with CP and their families, will evaluate existing health care, create conditions for a more equal health care, and develop new technologies to improve the health care management of people with CP.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13883

Decomposing gender inequalities in self-assessed health status in Liberia

Background: Understanding the magnitude of inequalities and drivers for reducing gender-related health inequalities is crucial in developing countries. This is particularly the case for Liberia with its very high level of gender-related inequalities in health and health outcomes.

Objective: This paper assesses the magnitude of gender health inequalities and the relative contribution of different factors to health inequality in Liberia.

Methods: Data came from the Liberian Household Income Expenditure Survey 2014. A two stage sampling methodology was used and 4,104 households were randomly selected and interviewed. The main variable of interest is dichotomised, good versus poor self-assessed health. Gender-related health inequality is assessed using the Oaxaca–Blinder decomposition for non-linear models. The decomposition reveals the magnitude of inequality and contributions of different factors.

Results: We found large gender disparities (0.054, p < 0.01) characterised by women disadvantages in health status. In addition, the gender health disparities are mostly pronounced in rural areas. About 54% of the gender inequalities in health status were explained by the differences in endowments. Equalizing access to information, wealth and utilization of mosquito nets would reduce the gender gaps by 44, 5 and 4%, respectively.

Conclusions: Addressing gender health inequalities inter alia requires access to health information (i.e. electronic and print media), gender responsive interventions that improve wealth in key sectors (i.e. education, employment, social protection, housing, and other appropriate infrastructure). In addition, the government, private sector and civil society should ensure that the health sector provides access to quality mosquito nets and improved health services including preventive care in order to reduce disease burden.

Modifiable Factors Explain Socioeconomic Inequalities in Children’s Dental Caries

The aim of this article was to quantify socioeconomic inequalities in dental caries experience among Australian children and to identify factors that explain area-level socioeconomic inequalities in children’s dental caries. We used data from the National Child Oral Health Survey conducted in Australia between 2012 and 2014 ( n = 24,664). Absolute and relative indices of socioeconomic inequalities in the dental caries experience in primary and permanent dentition (decayed, missing, and filled surfaces [dmfs] and DMFS, respectively) were estimated. In the first stage, we conducted multilevel negative binomial regressions to test the association between area-level Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) and dental caries experience (dmfs for 5- to 8-y-olds and DMFS for 9- to 14-y-olds) after adjustment for water fluoridation status, sociodemographics, oral health behaviors, pattern of dental visits, and sugar consumption. In the second stage, we performed Blinder-Oaxaca and Neumark decomposition analyses to identify factors that explain most of the area-level socioeconomic inequalities in dental caries. Children had a mean dmfs of 3.14 and a mean DMFS of 0.98 surfaces. Children living in the most disadvantaged and intermediately disadvantaged areas had 1.96 (95% confidence interval, 1.69–2.27) and 1.45 (1.26–1.68) times higher mean dmfs and 1.53 (1.36–1.72) and 1.43 (1.27–1.60) times higher mean DMFS than those living in the most advantaged areas, respectively. Water fluoridation status (33.6%), sugar consumption (22.1%), parental educational level (14.2%), and dental visit patterns (12.7%) were the main factors explaining area-level socioeconomic inequalities in dental caries in permanent dentition. Among all the factors considered, the factors that contributed most in explaining inequalities in primary dental caries were dental visits (30.3%), sugar consumption (20.7%), household income (20.0%), and water fluoridation status (15.9%). The inverse area-level socioeconomic inequality in dental caries was mainly explained by modifiable risk factors, such as lack of fluoridated water, high sugar consumption, and an unfavorable pattern of dental visits.

Racial/ethnic differences in 12-month prevalence and persistence of mood, anxiety, and substance use disorders: Variation by nativity and socioeconomic status

BACKGROUND

Despite equivalent or lower lifetime and past-year prevalence of mental disorder among racial/ethnic minorities compared to non-Latino Whites in the United States, evidence suggests that mental disorders are more persistent among minorities than non-Latino Whites. But, it is unclear how nativity and socioeconomic status contribute to observed racial/ethnic differences in prevalence and persistence of mood, anxiety, and substance disorders.

METHOD

Data were examined from a coordinated series of four national surveys that together assessed 21,024 Asian, non-Latino Black, Latino, and non-Latino White adults between 2001 and 2003. Common DSM-IV mood, anxiety, and substance disorders were assessed using the Composite International Diagnostic Interview. Logistic regression analyses examined how several predictors (e.g., race/ethnicity, nativity, education, income) and the interactions between those predictors were associated with both 12-month disorder prevalence and 12-month prevalence among lifetime cases. For the second series of analyses, age of onset and time since onset were used as additional control variables to indirectly estimate disorder persistence.

RESULTS

Non-Latino Whites demonstrated the highest unadjusted 12-month prevalence of all disorder types (p < 0.001), though differences were also observed across minority groups. In contrast, Asian, Latino, and Black adults demonstrated higher 12-month prevalence of mood disorders among lifetime cases than Whites (p < 0.001) prior to adjustments Once we introduced nativity and other relevant controls (e.g., age, sex, urbanicity), US-born Whites with at least one US-born parent demonstrated higher 12-month mood disorder prevalence than foreign-born Whites or US-born Whites with two foreign parents (OR = 0.51, 95% CI = [0.36, 0.73]); this group also demonstrated higher odds of past-year mood disorder than Asian (OR = 0.59, 95% CI = [0.42, 0.82]) and Black (OR = 0.70, 95% CI = [0.58, 0.83]) adults, but not Latino adults (OR = 0.89, 95% CI = [0.74, 1.06]). Racial/ethnic differences in 12-month mood and substance disorder prevalence were moderated by educational attainment, especially among adults without a college education. Additionally, racial/ethnic minority groups with no more than a high school education demonstrated more persistent mood and substance disorders than non-Latino Whites; these relationships reversed or disappeared at higher education levels.

CONCLUSION

Nativity may be a particularly relevant consideration for diagnosing mood disorder among non-Latino Whites; additionally, lower education appears to be associated with increased relative risk of persistent mood and substance use disorders among racial/ethnic minorities compared to non-Latino Whites.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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