State income inequality, household income, and maternal mental and physical health: cross sectional national survey

Causal Assessment of Income Inequality on Self-Rated Health and All-Cause Mortality: A Systematic Review and Meta-Analysis

Policy Points Income is thought to impact a broad range of health outcomes. However, whether income inequality (how unequal the distribution of income is in a population) has an additional impact on health is extensively debated. Studies that use multilevel data, which have recently increased in popularity, are necessary to separate the contextual effects of income inequality on health from the effects of individual income on health. Our systematic review found only small associations between income inequality and poor self-rated health and all-cause mortality. The available evidence does not suggest causality, although it remains methodologically flawed and limited, with very few studies using natural experimental approaches or examining income inequality at the national level.

CONTEXT

Whether income inequality has a direct effect on health or is only associated because of the effect of individual income has long been debated. We aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality) and assess if these relationships are likely to be causal.

METHODS

We searched Medline, ISI Web of Science, Embase, and EconLit (PROSPERO: CRD42021252791) for studies considering income inequality and SRH or mortality using multilevel data and adjusting for individual-level socioeconomic position. We calculated pooled odds ratios (ORs) for poor SRH and relative risk ratios (RRs) for mortality from random-effects meta-analyses. We critically appraised included studies using the Risk of Bias in Nonrandomized Studies - of Interventions tool. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework and causality using Bradford Hill (BH) viewpoints.

FINDINGS

The primary meta-analyses included 2,916,576 participants in 38 cross-sectional studies assessing SRH and 10,727,470 participants in 14 cohort studies of mortality. Per 0.05-unit increase in the Gini coefficient, a measure of income inequality, the ORs and RRs (95% confidence intervals) for SRH and mortality were 1.06 (1.03-1.08) and 1.02 (1.00-1.04), respectively. A total of 63.2% of SRH and 50.0% of mortality studies were at serious risk of bias (RoB), resulting in very low and low certainty ratings, respectively. For SRH and mortality, we did not identify relevant evidence to assess the specificity or, for SRH only, the experiment BH viewpoints; evidence for strength of association and dose-response gradient was inconclusive because of the high RoB; we found evidence in support of temporality and plausibility.

CONCLUSIONS

Increased income inequality is only marginally associated with SRH and mortality, but the current evidence base is too methodologically limited to support a causal relationship. To address the gaps we identified, future research should focus on income inequality measured at the national level and addressing confounding with natural experiment approaches.

Inequality's on Tap: A Longitudinal Study of Area-Level Income Inequality and Alcohol Consumption Among Canadian Adolescents

PURPOSE

To determine if income inequality at the census division level is associated with alcohol consumption and abuse among junior high and high school students.

METHODS

Data on adolescents are from the Cannabis use, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study. Participant data (n = 19,759) were collected during three survey waves (2016-2017, 2017-2018, and 2018-2019) and linked to 30 census divisions within four Canadian provinces. Data on income inequality and other area-level factors were derived from the 2016 Canadian census. Multilevel logistic regression modelling was used to quantify the associations between income inequality, monthly alcohol consumption, and binge drinking.

RESULTS

After adjusting for covariates, students living in census divisions within the second and third quintiles of income inequality experienced an average 80% (OR = 1.80, 95% CI = 1.08-3.02) and 92% (OR = 1.92, 95% CI = 1.05-3.51) increased odds of engaging in monthly binge drinking, respectively, compared to those living in the first quintile. Similarly, adolescents living in census divisions within the second inequality quintile experienced an average 169% (OR = 2.69, 95% CI = 1.45, 4.99) increased odds of engaging in weekly binge drinking, compared to those living in the first quintile. There was no significant association between higher income inequality and current monthly alcohol consumption.

DISCUSSION

Moderate area-level income inequality within census divisions was adversely associated with alcohol consumption among adolescents. Future work should investigate the potential mechanisms that mediate this relationship.

Gene-environment interactions and their impact on human health

The molecular processes underlying human health and disease are highly complex. Often, genetic and environmental factors contribute to a given disease or phenotype in a non-additive manner, yielding a gene-environment (G × E) interaction. In this work, we broadly review current knowledge on the impact of gene-environment interactions on human health. We first explain the independent impact of genetic variation and the environment. We next detail well-established G × E interactions that impact human health involving environmental toxicants, pollution, viruses, and sex chromosome composition. We conclude with possibilities and challenges for studying G × E interactions.

Exploring the Needs and Expectations of Expectant and New Parents for an mHealth Application to Support the First 1000 Days of Life: Steps toward a Co-Design Approach

To improve maternal and child health, it is essential to adhere to health-promoting and preventive measures. However, reliable information as well as effective tools are not easy to identify in this field. Our cross-sectional study investigated the needs and expectations of expectant and new mothers and fathers as potential primary users of a hypothetical application supporting the first 1000 days of life. Between May and August 2022, we recruited expectant and new parents by administering an 83-item 5-point Likert scale questionnaire related to the content, functionalities, and technical features of the hypothetical app. We stratified responses using sociodemographic characteristics and then performed ward hierarchical clustering. The 94 women and 69 men involved in our study generally agreed with the proposed content, but expressed low interest in certain app functionalities or features, including those related to the interaction mechanism and interactivity. Women were generally more demanding than men. Our findings, resulting from the engagement of end-users, may be useful for designers and technology providers to implement mHealth solutions that, in addition to conveying reliable information, are tailored to the needs and preferences of end-users in the first 1000 days of life.

Research on the heterogeneous effects of residents' income on mental health

The influence of residents' income on mental health is complex, and there are heterogeneous effects of residents' income on different types of mental health. Based on the annual panel data of 55 countries from 2007 to 2019, this paper divides residents' income into three dimensions: absolute income, relative income and income gap. Mental health is divided into three aspects: subjective well-being, prevalence of depression and prevalence of anxiety. Panel Tobit model is used to study the heterogeneous impact of residents' income on mental health. The results show that, on the one hand, different dimensions of residents' income have a heterogeneous impact on mental health, specifically, absolute income has a positive impact on mental health, while relative income and income gap have no significant impact on mental health. On the other hand, the impact of different dimensions of residents' income on different types of mental health is heterogeneous. Specifically, absolute income and income gap have heterogeneous effects on different types of mental health, while relative income has no significant impact on different types of mental health.

Income and Health Perceptions in an Economically Disadvantaged Community: A Qualitative Case Study from Central Florida

The link between income and adverse health outcomes continues to be problematic among racially and economically segregated urban communities. Although the consequences of living in areas of concentrated disadvantage have been delineated, there is a dearth of knowledge on how citizens from such areas perceive the effects of neighborhood characteristics on their individual and community health. This qualitative study explored how minority residents ( N = 23) viewed the intersectionality of income and health within their urban neighborhoods of economic distress. Focus groups were conducted using semi-structured interviews to better understand health concerns, needs, and barriers for individuals and their community. The main finding highlighted how residents desired to be healthy, but economic barriers prevented them from maintaining a healthy lifestyle and diet. While residing in a concentrated disadvantaged community, lack of income and power contributed to stress and fear that forced residents to prioritize survival over their wellbeing. Implications for improving individual and community health include operating within a systems framework to affect collective efficacy and empowerment among residents of low-income neighborhoods.

Neighbourhood Income Inequality and General Psychopathology at 3-Years of Age

BACKGROUND

Several studies have linked neighbourhood environment to preschool-aged children's behavioural problems. Income inequality is an identified risk factor for mental health among adolescents, however, little is known as to whether this relationship extends to younger children.

OBJECTIVE

To explore the association between neighbourhood-level income inequality and general psychopathology problems among preschool-aged children.

METHODS

We analyzed data from the All Our Families (AOF) longitudinal cohort located in Calgary, Canada at 3-years postpartum. The analytical sample consisted of 1615 mother-preschooler dyads nested within 184 neighbourhoods. Mothers completed the National Longitudinal Survey of Children and Youth Child Behaviour Checklist (NLSCY-CBCL), which assessed internalizing and externalizing symptoms. Income inequality was assessed via the Gini coefficient, which quantifies the unequal distribution of income in society. Mixed effects linear regression assessed the relationship between neighbourhood income inequality and preschooler's general psychopathology.

RESULTS

The mean Gini coefficient across the 184 neighbourhoods was 0.33 (SD = 0.05; min, max: 0.20-0.56). In the fully adjusted model income inequality was not associated with general psychopathology in children β = 0.07 (95%CI: -0.29, 0.45). Neighbourhood environment accounted for 0.5% of the variance in psychopathology in children.

CONCLUSION

The lack of significant findings may be due to a lack of statistical power in the study. Future studies should investigate this relationship with appropriately powered studies, and over time, to assess if income inequality is a determinant of preschooler psychopathology in Canada.

The longitudinal relationships among poverty, material hardship, and maternal depression in the USA: a latent growth mediation model

This study aims to understand the direct and indirect effects of poverty trajectories on maternal depression trajectories mediated by material hardship trajectories. A latent growth mediation model was tested using a predominantly low-income and mostly unmarried sample of mothers from the Fragile Families and Child Wellbeing Study, a national birth cohort of racially diverse mothers (N = 3999). Measures included family poverty, material hardship, and maternal depression from 5 waves of data which tracked mothers starting 1 year after childbirth until the child reached 15 years of age. The results revealed that (1) family poverty was associated with material hardship and maternal depression, and material hardship was related to maternal depression at the trajectory level and the rate of change, with the exception of the relationships between the rate of change in family poverty and the rate of change in maternal depression; (2) material hardship mediated the relationship between family poverty and maternal depression at the initial trajectory levels, and the rate of change in material hardship fully mediated the relationship between the rate of change in poverty and the rate of change in maternal depression. This study provides further evidence that alleviating material hardship might be a promising avenue to reducing maternal depression.

Do social support and community engagement act as mechanisms in the association between neighbourhood income inequality and the mental health of mothers in Calgary, Canada? A mediation analysis

PURPOSE

According to the social determinants of health framework, income inequality is a potential risk factor for adverse mental health. However, few studies have explored the mechanisms suspected to mediate this relationship. The current study addresses this gap through a mediation analysis to determine if social support and community engagement act as mediators linking neighbourhood income inequality to maternal anxiety and depressive symptoms within a cohort of new mothers living in the City of Calgary, Canada.

METHODS

Data collected at three years postpartum from mothers belonging to the All Our Families (AOF) cohort were used in the current study. Maternal data were collected between 2012 and 2015 and linked to neighbourhood socioeconomic data from the 2006 Canadian Census. Income inequality was measured using Gini coefficients derived from 2006 after-tax census data. Generalized structural equation models were used to quantify the associations between income inequality and mental health symptoms, and to assess the potential direct and indirect mediating effects of maternal social support and community engagement.

RESULTS

Income inequality was not significantly associated with higher depressive symptoms (β = 0.32, 95%CI = -0.067, 0.70), anxiety symptoms (β = 0.11, 95%CI = -0.39, 0.60), or lower social support. Income inequality was not associated with community engagement. For the depression models, higher social support was significantly associated with lower depressive symptoms (β = -0.13, 95%CI = -0.15, -0.097), while community engagement was not significantly associated with depressive symptoms (β = 0.059, 95%CI = -0.15, 0.27). Similarly, for the anxiety models, lower anxiety symptoms were significantly associated with higher levels of social support (β = -0.17, 95%CI = -0.20, -0.13) but not with higher levels of community engagement (β = 0.14, 95%CI = -0.14, 0.41).

CONCLUSION

The current study did not find clear evidence for social support or community engagement mediating the relationship between neighbourhood income inequality and maternal mental health. Future investigations should employ a broader longitudinal approach to capture changes in income inequality, potential mediators, and mental health symptomatology over time.

Motherhood Health Penalty: Impact of Fertility on Physical and Mental Health of Chinese Women of Childbearing Age

Background

The negative consequences of childbearing on mothers are called the motherhood penalty, and it manifests in the aspects of women's physical and mental health. In May 2021, China relaxed its birth policy that allowed a married couple to have three children. It gives women the opportunity to have more children, but also may increase more risks to mothers' physical and mental health.

Objectives

The objectives of this study were to clarify the relationships between the fertility and the physical/mental health of women of childbearing age and empirically confirm the existence of the motherhood health penalty in China.

Materials and Methods

Using a nationally representative dataset from the China Labor-force Dynamics Survey 2018, we examined the effects of fertility on the physical and mental health of Chinese women of childbearing age. Physical health was self-rated, and mental health was assessed according to the Center for Epidemiological Studies Depression scale. The instrumental variable approach and the models of inverse probability of treatment weighting of propensity scores and regression adjustment were employed to overcome the endogeneity between fertility and health of women.

Results

The empirical results showed that the total number of births had significant adverse impacts on the physical and mental health of women of childbearing age, which empirically demonstrated the existence of the motherhood health penalty in China. The results of heterogeneity analysis indicated that the physical and mental health of the rural women was more easily affected by childbearing compared with that of the urban samples. In a mechanism analysis, the pathways of income and the multiple roles played by mothers were found to mediate the impacts of the total number of births on the physical and mental health of women. The robustness checks showed that the results of this study were robust.

Conclusions

The findings of this study extend the motherhood penalty to the health domain, and they have important implications for improving healthcare policy for women of childbearing age in China and other countries and regions and promoting gender equality in the healthcare field.

Assessing the causal relationship between income inequality and mortality and self-rated health: protocol for systematic review and meta-analysis

BACKGROUND

Income inequality has been linked to health and mortality. While there has been extensive research exploring the relationship, the evidence for whether the relationship is causal remains disputed. We describe the methods for a systematic review that will transparently assess whether a causal relationship exists between income inequality and mortality and self-rated health.

METHODS

We will identify relevant studies using search terms relating to income inequality, mortality, and self-rated health (SRH). Four databases will be searched: MEDLINE, ISI Web of Science, EMBASE, and the National Bureau of Economic Research. The inclusion criteria have been developed to identify the study designs best suited to assess causality: multilevel studies that have conditioned upon individual income (or a comparable measure, such as socioeconomic position) and natural experiment studies. Risk of bias assessment of included studies will be conducted using ROBINS-I. Where possible, we will convert all measures of income inequality into Gini coefficients and standardize the effect estimate of income inequality on mortality/SRH. We will conduct random-effects meta-analysis to estimate pooled effect estimates when possible. We will assess causality using modified Bradford Hill viewpoints and assess certainty using GRADE.

DISCUSSION

This systematic review protocol lays out the complexity of the relationship between income inequality and individual health, as well as our approach for assessing causality. Understanding whether income inequality impacts the health of individuals within a population has major policy implications. By setting out our methods and approach as transparently as we can, we hope this systematic review can provide clarity to an important topic for public policy and public health, as well as acting as an exemplar for other "causal reviews".

The association between income inequality and adult mental health at the subnational level-a systematic review

PURPOSE

A systematic review was undertaken to determine whether research supports: (i) an association between income inequality and adult mental health when measured at the subnational level, and if so, (ii) in a way that supports the Income Inequality Hypothesis (i.e. between higher inequality and poorer mental health) or the Mixed Neighbourhood Hypothesis (higher inequality and better mental health).

METHODS

Systematic searches of PsycINFO, Medline and Web of Science databases were undertaken from database inception to September 2020. Included studies appeared in English-language, peer-reviewed journals and incorporated measure/s of objective income inequality and adult mental illness. Papers were excluded if they focused on highly specialised population samples. Study quality was assessed using a custom-developed tool and data synthesised using the vote-count method.

RESULTS

Forty-two studies met criteria for inclusion representing nearly eight million participants and more than 110,000 geographical units. Of these, 54.76% supported the Income Inequality Hypothesis and 11.9% supported the Mixed Neighbourhood Hypothesis. This held for highest quality studies and after controlling for absolute deprivation. The results were consistent across mental health conditions, size of geographical units, and held for low/middle and high income countries.

CONCLUSIONS

A number of limitations in the literature were identified, including a lack of appropriate (multi-level) analyses and modelling of relevant confounders (deprivation) in many studies. Nonetheless, the findings suggest that area-level income inequality is associated with poorer mental health, and provides support for the introduction of social, economic and public health policies that ameliorate the deleterious effects of income inequality.

CLINICAL REGISTRATION NUMBER

PROSPERO 2020 CRD42020181507.

Is neighbourhood income inequality associated with maternal mental health? A longitudinal analysis of pregnant and new mothers living in Calgary, Alberta

OBJECTIVES

Rising income inequality is a potential risk factor for poor mental health, however, little work has investigated this link among mothers. Our goal was to determine if neighbourhood-level income inequality was associated with maternal mental health over time.

DESIGN

Secondary data analysis using a retrospective cohort study design.

SETTING AND PARTICIPANTS

Data from the All Our Families (AOF) ongoing cohort study in the city of Calgary (Canada) were used, with our sample including 2461 mothers. Participant data were collected at six time points from 2008 to 2014, corresponding to <25 weeks of pregnancy to 3 years post partum. AOF mothers were linked to 196 geographically defined Calgary neighbourhoods using postal code information and 2006 Canada Census data.

MAIN OUTCOME MEASURES

Anxiety symptoms measured using the Spielberger State Anxiety Inventory, and depressive symptoms measured using the Edinburgh Postnatal Depression Scale and the Centre for Epidemiologic Studies-Depression Scale.

RESULTS

Multilevel regression modelling was used to quantify the associations between neighbourhood-level income inequality and continuous mental health symptoms over time. For anxiety symptoms, the interaction term between neighbourhood Gini and time was significant (β=0.0017, 95% CI=0.00049 to 0.0028, p=0.005), indicating an excess rate of change over time. Specifically, a SD increase in Gini (Z-score) was associated with an average monthly rate increase in anxiety symptom scores of 1.001% per month. While depressive symptom scores followed similar longitudinal trajectories across levels of income inequality, we did not find significant evidence for an association between inequality and depressive symptoms. There was no evidence of a cross-level interaction between inequality and household income on either outcome.

CONCLUSION

Income inequality within neighbourhoods appears to adversely impact the mental health trajectories of pregnant and new mothers. Further research is needed to understand the mechanisms that explain this relationship, and how interventions to reduce income inequality could benefit mental health.

The Effect of China's Compulsory Education Reforms on Physiological Health in Adulthood: A Natural Experiment

Lower education is related to higher biological risks for physiological health, but it remains unclear whether the risks can be reduced through policies aimed at increasing years of education. We utilized China's compulsory education reforms as a unique natural experiment, which stipulates that primary and lower secondary education is mandatory and free for all school-age children. Using a regression discontinuity design (RDD), we assessed the effect of the reform eligibility on biomarkers. The reforms resulted in an increase in years of education for those from communities with the middle 1/3 per capita income (PCI) (β = 2.44, 95% CI = 0.23 - 4.64). Reform eligibility had no impact on allostatic risks for the total sample (β = 0.065, 95% CI = -0.70 - 0.83) and for those from communities with the lowest (β = 0.35, 95% CI = -0.77 - 1.47) or highest third of PCI (β = 0.68, 95% CI = -0.64 - 2.00), while it reduced the metabolic risk (β = -0.14, 95% CI = -0.26 - -0.015) and total allostatic load (β = -1.58, 95% CI = -3.00 - -0.16) among those from communities with the middle third PCI. The results were confirmed by sensitivity analyses of different placebo cutoff points and bandwidths. The reforms led to better physiological health to some extent, but the effect only manifested in people from communities with a moderate community PCI, and had little impact on affluent or disadvantaged groups. Our findings stressed that the institutional context and respondents' socioeconomic environment must be taken into account when assessing the health impact of China's compulsory education reforms.

Inequality in Place: Effects of Exposure to Neighborhood-Level Economic Inequality on Mortality

This study contributes to the debate on whether income inequality is harmful for health by addressing several analytical weaknesses of previous studies. Using the Panel Study of Income Dynamics in combination with tract-level measures of income inequality in the United States, we estimate the effects of differential exposure to income inequality during three decades of the life course on mortality. Our study is among the first to consider the implications of income inequality within U.S. tracts for mortality using longitudinal and individual-level data. In addition, we improve upon prior work by accounting for the dynamic relationship between local areas and individuals' health, using marginal structural models to account for changes in exposure to local income inequality. In contrast to other studies that found no significant relation between income inequality and mortality, we find that recent exposure to higher local inequality predicts higher relative risk of mortality among individuals at ages 45 or older.

Economic inequality in malnutrition: a global systematic review and meta-analysis

OBJECTIVE

To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

METHODS

We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

RESULTS

From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

CONCLUSIONS

There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO REGISTRATION NUMBER

CRD42020201572.

Socioeconomic inequalities in co-morbidity of overweight, obesity and mental ill-health from adolescence to mid-adulthood in two national birth cohort studies

AIM

To examine socioeconomic inequalities in comorbidity risk for overweight (including obesity) and mental ill-health in two national cohorts. We investigated independent effects of childhood and adulthood socioeconomic disadvantage on comorbidity from childhood to mid-adulthood, and differences by sex and cohort.

METHODS

Data were from 1958 National Child Development Study (NCDS58) and 1970 British Cohort Study (BCS70) [total N=30,868, 51% males] assessed at ages 10, 16, 23/26, 34 and 42 years. Socioeconomic indicators included childhood and adulthood social class and educational level. Risk for i. having healthy BMI and mental ill-health, ii. overweight and good mental health, and iii. overweight and mental ill-health was analysed using multinomial logistic regression.

FINDINGS

Socioeconomic disadvantage was consistently associated with greater risk for overweight-mental ill-health comorbidity at all ages (RRR 1.43, 2.04, 2.38, 1.64 and 1.71 at ages 10, 16, 23, 34 and 42 respectively for unskilled/skilled vs. professional/managerial class). The observed inequalities in co-morbidity were greater than those observed for either condition alone (overweight; RRR 1.39 and 1.25, mental ill-health; 1.36 and 1.22 at ages 16 and 42 respectively, for unskilled/skilled vs. professional/managerial class). In adulthood, both childhood and adulthood socioeconomic disadvantage were independently associated with comorbid overweight-mental ill-health, with a clear inverse gradient between educational level and risk for comorbidity. For instance, for the no education group (compared to university education) the RRR is 6.11 (95% CI 4.31-8.65) at age 34 and 4.42 (3.28-5.96) at age 42. There were no differences observed in the extent of inequalities by sex and differences between cohorts were limited.

INTERPRETATION

While socioeconomic disadvantage in childhood and adulthood are consistently and independently associated with greater risk for mental ill-health and being overweight separately, these associations are even larger for their comorbidity across the lifecourse. These findings are significant given the increasing global prevalence of obesity and mental ill-health, and their implications for lifelong health and mortality.

FUNDING

This research was supported by grants from the Wellcome Trust (ISSF3/ H17RCO/NG1) and Medical Research Council (MRC) [MC_UU_00019/3].

Pain experience in an aging adult population during a 10-year follow-up

OBJECTIVES

This 10-year follow-up study aimed to examine the persistence of SF-36 pain intensity and pain-related interference and to identify baseline factors that may relate to pain experience among community-dwelling aging adults.

METHODS

Questionnaire and clinical data on a total of 1,954 participants (mean age at baseline 63 years) were collected in 2002, 2005, 2008, and 2012. Based on pain reports, four pain intensity, pain interference (PIPI) groups were formed at each time point: PIPI group I: none to mild pain intensity and interference; II: moderate to extreme pain intensity, none to mild pain-related interference; III: None to mild pain intensity, moderate to extreme pain-related interference, IV: Moderate to extreme pain intensity and interference.

RESULTS

Participants with the most pain at baseline improved their pain situation the most during the follow-up. Higher BMI was associated with pain interference, and metabolic syndrome (MetS) and musculoskeletal diseases with both pain intensity and interference (p<0.05, statistically significant interaction between pain intensity and pain interference) at baseline. According to multivariate logistic regression analysis the following baseline characteristics were associated with remaining in PIPI group I throughout the follow-up: presence of musculoskeletal disease (OR 0.22 [95% CI 0.16-0.30]), high BMI (OR 0.93 [95% CI 0.90-0.97]), high household income (OR 1.46 [95% CI 1.07-1.98]), good childhood home environment (OR 1.03 [95% CI 1.00-1.05]).

CONCLUSIONS

Multiple factors may affect pain persistence in late adulthood with varying effect on pain intensity and pain-related interference. Pain situation of even those with most pain may be improved.

How does neighbourhood socio-economic status affect the interrelationships between functioning dimensions in first episode of psychosis? A network analysis approach

The links between psychosis and socio-economic disadvantage have been widely studied. No previous study has analysed the interrelationships and mutual influences between functioning dimensions in first episode of psychosis (FEP) according to their neighbourhood household income, using a multidimensional and transdiagnostic perspective. 170 patients and 129 controls, participants in an observational study (AGES-CM), comprised the study sample. The WHO Disability Assessment Schedule (WHODAS 2.0) was used to assess functioning, whereas participants' postcodes were used to obtain the average household income for each neighbourhood, collected by the Spanish National Statistics Institute (INE). Network analyses were conducted with the aim of defining the interrelationships between the different dimensions of functioning according to the neighbourhood household income. Our results show that lower neighbourhood socioeconomic level is associated with lower functioning in patients with FEP. Moreover, our findings suggest that "household responsibilities" plays a central role in the disability of patients who live in low-income neighbourhoods, whereas "dealing with strangers" is the most important node in the network of patients who live in high-income neighbourhoods. These results could help to personalize treatments, by allowing the identification of potential functioning areas to be prioritized in the treatment of FEP according to the patient's neighbourhood characteristics.

Generalized anxiety disorder in type 2 diabetes mellitus: prevalence and clinical characteristics

Objective:

This study investigated the prevalence of generalized anxiety disorder (GAD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

Methods:

This retrospective observational study was conducted with a random sample of patients from the entire population of National Health Insurance enrollees during 2000-2010 and used ICD-9-CM diagnostic codes to identify T2DM patients and GAD. The prevalence of GAD was compared between T2DM patients and the general population.

Results:

Between 2000 and 2010, the prevalence of GAD was significantly greater in the T2DM patients than the general population, while the increase of GAD was higher in the general population (from 0.25 to 0.63%) than among T2DM patients (from 0.81 to 1.03%). In T2DM patients, GAD was associated with female gender, a Charlson Comorbidity Index ≥ 1, diabetes mellitus duration > 9 years, and the following comorbidities: congestive heart failure, peripheral vascular disease, and depressive disorder. The prevalence of GAD among T2DM patients was negatively associated with rapid-acting insulin injection therapy and with the use of metformin and sulfonylureas.

Conclusion:

Since the prevalence of GAD was greater among T2DM patients than the general population, public health initiatives are needed to prevent and treat GAD in T2DM patients, specifically those with the above mentioned risk factors.

Are There Heterogeneous Impacts of National Income on Mental Health?

Understanding heterogeneous impact and mechanisms between national income and mental health are crucial to develop prevention and intervention strategies. Based on panel data from 2007 to 2017, this study explores the heterogeneous impact of national income on different types of mental health. Then, it analyzes the heterogeneous impact among countries with different income levels. Furthermore, the heterogeneous moderating effects of national income on mental health mechanisms are elaborated and the findings reveal several key conclusions: firstly, national income exerts a heterogeneous impact on different types of mental health. Rising national income is conducive to increase people’s happiness and reduce their prevalence of anxiety disorders, but it increases the prevalence of depression disorders. Secondly, national income has a heterogeneous impact on different types of mental health among countries with different income levels. Furthermore, the heterogeneous influence mechanism of national income on mental health is mainly reflected in different types of mental health. Unemployment, social support and freedom can moderate the relationship between national income and depression, while social support, positive affect and negative affect can moderate the relationship between national income and anxiety. Finally, based on the conclusions of quantitative analysis, some important policy recommendations are proposed for policy makers.

The impact of intimate partner violence on the trajectory of perinatal depression: a cohort study in a Chinese sample

Abstract.

AIMS

Intimate partner violence (IPV) is an important risk factor for perinatal depression (PND). But IPV's impact on the natural prognosis of PND symptoms is not well understood. We tested two hypotheses: (1) pregnant women with IPV experiences will exhibit more severe PND symptoms than women without IPV experience; (2) IPV experience will impede the recovery prognosis of PND. We also explored the contribution of IPV to PND comparing with other risk factors.

METHOD

The sample is comprised of 813 pregnant women followed through perinatal period in Hunan, China. We assessed IPV experience using items from the Short Form of the Revised Conflict Tactics Scale (CTS2S), and PND symptoms via the Edinburgh Postnatal Depression Scale (EPSD). We conducted Linear Mixed-effects Model to compare the trajectories of PND symptoms between victims and non-victims and a multistage Generalised Estimating Equations Model to explore salient factors on the trajectory of PND symptoms.

RESULTS

There were 90 participants (11.07%) who reported IPV experience in the past 12 months. With respect to physical, psychological and sexual violence, the prevalence was 4.55% (37/813), 9.23% (75/813) and 2.34% (19/813). Victims reported more severe PND symptoms (t = 5.30, p < 0.01) and slower decreasing slope of trajectories (t = 28.89, p < 0.01). The PND trajectory was associated with IPV experience (OR = 3.78; 95% CI 1.39-10.26), social support (OR = 0.93; 95% CI 0.88-0.97), positive coping strategies (OR = 0.85; 95% CI 0.80-0.91), negative coping strategies (OR = 1.25; 95% CI 1.14-1.37) and monthly income of $0.15-$298.36 (compared to no income, OR = 0.0075; 95% CI 0.00052-0.11).

CONCLUSIONS

The findings suggest the reported prevalence of IPV is lower in Hunan than most of the previous studies during perinatal period in other provinces of China, and IPV victimisation is associated with increased severity and slowed prognosis of PND symptoms. Future studies that screen for victimisation and establish its explicit mechanism to the poorer prognosis of PND symptoms would benefit the prevention and treatment of PND.

Perinatal mental distress in a rural Ethiopian community: a critical examination of psychiatric labels

BACKGROUND

Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress.

METHODS

We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data.

RESULTS

Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used.

CONCLUSIONS

This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.

Adherence to Antidepressants in Underserved Communities: A Comparison of Electronic Monitoring and Self-report Measures

Nonadherence to antidepressants is widespread and poses a significant barrier to optimal management and treatment of depression in community settings. The objective of this study was to compare self-reported and electronic monitoring of adherence to antidepressants and to examine the relationship of these measures with depressive symptoms in a medically underserved community. Adherence to antidepressants was measured in 38 primary care patients from the West Philadelphia area using self-report and electronic monitoring (Medication Event Monitoring System caps). Self-report and electronic monitoring of antidepressant adherence showed fair agreement at baseline, slight agreement at 6 weeks, and slight agreement at 12 weeks. Adherence to antidepressants as assessed by electronic monitors was significantly associated with depression remission at 12 weeks [adjusted odds ratio 18.6, 95% confidence interval (1.05, 330.56)]. Compared with electronic monitoring, self-reported adherence tended to overestimate medication adherence to antidepressants. Adherence assessed by electronic monitoring was associated with depression remission.

Gender, income and mental health: The Turkish case

Gender gaps in health outcomes are frequently observed. Mental health disorders also display gender differences in various countries. This paper explores gender differences in mental health outcomes of individuals in Turkey. It aims to deliver additional evidence on associations between gender, income and mental health status by providing an empirical analysis from a developing country, Turkey. This study employs a nationally representative data set from Turkish Health Survey of 2016. It constructs an index for mental health at individual level by using polychoric principal component analysis. Conditional mixed process models are estimated for quantification of associations between gender, income and mental health measures. Empirical findings indicate that there is endogenous and positive relationship between household income level and mental health status of individuals in Turkey. Turkish females report lower mental health statuses than Turkish males. Furthermore, females are more likely to use mental health services in Turkey. Gender gaps in both mental health status and mental health service use are present in the Turkish case. Results of this study imply that mental health policies should avoid applying one-fit-all approaches.

To the Victors Go the Existential Spoils: The Mental-Health Benefits of Cultural Worldview Defense for People WHO Successfully Meet Cultural Standards and Valued Goals

Introduction: Research in support of terror management theory suggests that mortality concerns will activate symbolic defenses associated with cultural worldviews, and when these defenses are activated, mental health will benefit. However, no study to date has examined this process in full. We filled this gap, while testing the moderating effect of feeling successful vis-à-vis cultural value-standards.

Method: In two studies, we hypothesized that participants who feel successful at meeting cultural standards would engage cultural worldview defense (WVD) following mortality salience (MS), and as a consequence of their defensiveness, would experience greater mental health.

Results: In Study 1, MS increased pro-American WVD only among relatively wealthy participants, which in turn reduced death-thought accessibility. In Study 2, MS increased pro-American WVD only among participants primed with felt success (vs. failure), which in turn reduced anxiety and depression.

Conclusions: Culture can relieve death-related distress and promote mental health to the extent that it provides feelings of success.

Relative deprivation and suicide risk in South Korea

Psychosocial stress and the related biochemical response have been hypothesized as a potential mechanism underlying the link between relative deprivation and mortality. While suicide is known as the likely manifestation of severe mental illness, less is known about the effect that relative deprivation has on suicide risk. Using the 2012 to 2018 waves of the Korean Welfare Panel Study, we examined the association between relative deprivation in income and suicide risk among South Koreans aged 25 or older. Relative deprivation is assessed with the Yitzhaki index, Deaton index, and income rank within the reference group, and suicide risk is measured as suicidal ideation and suicide planning or attempt in the preceding year. Adjusted for absolute income and other socioeconomic characteristics, the odds ratios of reporting suicidal ideation for each 10000 k KRW (8300 USD) increase in the Yitzhaki index were around 1.42 (95% CI: 1.08-1.87) to 1.72 (95% CI: 1.30-2.28). The estimated odds ratios were in the range of 1.70 (95% CI: 1.04-2.78) to 1.95 (95% CI: 1.26-3.02) for suicide planning or attempt. The association between relative deprivation in income and suicidal ideation was found significant only for men, not for women. The inferences were robust to various definitions of relative deprivation and reference group. Taken together, our findings suggest that relative deprivation in income is independently associated with higher odds of suicidal ideation and suicide planning or attempt over and above the effect of absolute income and material living conditions. Narrowing the income gap between individuals would be an effective policy response to a suicide epidemic in South Korea.

Postnatal depressive symptoms display marked similarities across continents

BACKGROUND

Postnatal depressive symptoms measured by the Edinburgh Postnatal Depression Scale (EPDS) are reported to display measurement variance regarding factor structure and the frequency of specific depressive symptoms. However, postnatal depressive symptoms measured by EPDS have not been compared between women representing three continents.

METHODS

A cross-sectional study including birth cohort samples from Denmark, Vietnam and Tanzania. Women were included during pregnancy at routine care sites. Depressive symptoms were self-reported 40-90 days postpartum using the EPDS. Exploratory and confirmatory factor analyses and generalized additive regression models were performed.

RESULTS

A total of N = 4,516 participated in the study (Denmark N = 2,069, Vietnam N = 1,278, Tanzania N = 1,169). Factor analyses identified three factors (anhedonia, anxiety and depression) that were almost identical in the three study populations. The only variation between countries was that the item 'self-harm' loaded differently. Women from Tanzania and Denmark were more likely to have an EPDS total score above cut-off 12 (12.6% and 6.4%), compared to women from Vietnam (1.9%) (p<0.001). A low level of education was associated with significantly more depressive symptoms after adjusting for country (p<0.001).

LIMITATIONS

EPDS data was collected at a later time point in the Danish sample.

CONCLUSIONS

Postnatal depressive symptoms constitute a three-factor model across cultures including the factors anhedonia, anxiety and depression. The frequency of postnatal depressive symptoms differs between high-, medium-, and low-income countries. However, clinicians should bear in mind that low-educated women worldwide are more likely to experience postnatal depressive symptoms.

Coastal proximity and mental health among urban adults in England: The moderating effect of household income

After adjusting for covariates, self-reported general health in England is higher among populations living closer to the coast, and the association is strongest amongst more deprived groups. We explored whether similar findings were present for mental health using cross-sectional data for urban adults in the Health Survey for England (2008-2012, N ≥25,963). For urban adults, living ≤1 km from the coast, in comparison to >50 km, was associated with better mental health as measured by the GHQ12. Stratification by household income revealed this was only amongst the lowest-earning households, and extended to ≤5 km. Our findings support the contention that, for urban adults, coastal settings may help to reduce health inequalities in England.

Determinants of Health Trajectories in England and the United States: An Approach to Identify Different Patterns of Healthy Aging

Background

Aging is a multidimensional process with a remarkable interindividual variability. This study is focused on identifying groups of population with similar aging patterns, and to define the health trajectories of these groups. Sociodemographic and health determinants of these trajectories are also identified.

Methods

Data from the English Longitudinal Study of Aging (ELSA) and the Health and Retirement Study (HRS) were used. A set of self-reported health items and measured tests were used to generate a latent health metric by means of a Bayesian multilevel IRT model, assessing the ability of the metric to predict mortality. Then, a Growth Mixture Model (GMM) was conducted in each study to identify latent classes and assess health trajectories. Kaplan-Meier survival curves were obtained for each class and a multinomial logistic regression was used to identify determinants of these trajectories.

Results

The health score generated showed an adequate ability to predict mortality over 10 years in ELSA (AUC = 0.74; 95% CI: 0.72, 0.75) and HRS (AUC = 0.74; 95% CI: 0.73, 0.75). By means of GMM, four latent classes were identified in ELSA and five in HRS. Chronic conditions, no qualification and low level of household wealth were associated to the classes which showed a higher mortality in both studies.

Conclusion

The method based on the creation of a common metric of health and the use of GMM to identify similar patterns of aging, allows for the comparison of trajectories of health across longitudinal surveys. Multimorbidity, educational level, and household wealth could be considered as determinants associated to these trajectories.

Inequality within a community at the neighborhood level and the incidence of mood disorders in Japan: a multilevel analysis

PURPOSE

This study analyzes whether income inequality within a community at the neighborhood level is associated with incidence of mood disorder in Japan.

METHODS

A retrospective cohort study was performed using the data of 116,658 National Health Insurance beneficiaries aged between 20 and 69 in Chiba City, Japan. To evaluate income inequality within a community, the Gini coefficient within a 30-min walking distance from an individual's residence was calculated using income distribution estimated by the National Census and the Housing and Land Survey 2013. Incidence of mood disorder was determined through insurance claims submitted from April 1, 2013, to March 31, 2016. A multilevel logistic analysis with three levels-the individual, household, and residential district-was performed to evaluate the association.

RESULTS

Income inequality within a community at the neighborhood level was not associated with incidence of mood disorder in the models with and without equivalent household income (p for trend = 0.856 and 0.947, respectively). No difference was observed in the impact of the Gini coefficient among income levels, lower versus higher income groups (p for interaction between Gini coefficient and household income = 0.967). In contrast, lower equivalent income at the household level was significantly associated with higher incidence of mood disorder (p for trend < 0.001).

CONCLUSIONS

While we confirmed that lower income at the household level itself had an adverse effect on mental health, income inequality within a community at the neighborhood level was not a significant factor for incidence of mood disorder in Japan.

Examining the Differing Effects of Economic Hardship and Poor Maternal Wellbeing on Cumulative Exposure to Adverse Childhood Experiences

Extensive research supports a strong and cumulative relationship between adverse childhood experiences (ACEs) and risky adult behaviors, mental health disorders, diseases, and health status. Additional factors, such as poor maternal wellbeing and economic hardship, compound the detrimental health and wellbeing implications associated with childhood exposure to ACEs. However, limited research has explored the differentiating effects of economic hardship and maternal wellbeing on a child's cumulative ACE exposure. This study examined the differing effects of poor maternal wellbeing and economic hardship on a child's exposure to ACEs. This study used a random sub-sample (n = 4000) from the 2011 to 2012 National Survey on Children's Health (NSCH), a nationally representative cross-sectional study of children (N = 95,677) between birth and 17 years old. Confirmatory factor analysis results revealed greater economic hardship had a significant direct effect on a child's ACE exposure and poorer maternal wellbeing. Poor maternal wellbeing had a significant mediation-like effect on the relationship between economic hardship and a child's cumulative ACE exposure. Practice and policy implications include early ACE assessments tailored to identify children and families experiencing adversity across multiple domains.

Income inequality and racial disparities in pregnancy-related mortality in the US

In this ecological study, we examined the associations between state-level income inequality and pregnancy-related mortality among non-Hispanic (NH) black and NH white populations across the US. We estimated total population and race-specific 5-year pregnancy-related mortality ratios in each state based on national death and live birth records from 2011 to 2015. We obtained data on Gini coefficients for income inequality and population-level characteristics from the US Census American Community Survey. Poisson regression with robust standard errors estimated pregnancy-related mortality rate ratios (RR) and 95% confidence intervals (CI) associated with a one unit increase in income inequality overall and separately within black and white populations. Adjusted linear regression models estimated the associations between income inequality and magnitude of the absolute and relative racial inequity in pregnancy-related mortality within states. Across all states, increasing contemporaneous income inequality was associated with a 15% and 5-year lagged inequality with 14% increase in pregnancy-related mortality among black women (aRR = 1.15, 95% CI = 1.05; 1.25 and aRR = 1.14, 95% CI = 1.04; 1.24, respectively) after controlling for states' racial compositions and socio-economic conditions. In addition, both lagged and contemporaneous income inequality were associated with larger absolute and relative racial inequities in pregnancy-related mortality. These findings highlight the role of contextual factors in contributing to pregnancy-related mortality among black women and the persistent racial inequity in maternal death in the US.

Infant Vagal Tone and Maternal Depressive Symptoms: A Bottom-Up Perspective

Children vary in their susceptibility to environmental exposures such as maternal depression, but little is known about how children shape those same environments. When raising an infant with low arousal, mothers at risk of depression may experience decreased parenting self-efficacy and increased depressive symptoms. We evaluated a longitudinal mediated moderation model that hypothesized interactive effects of infant vagal tone (indexed by respiratory sinus arrhythmia [RSA]) and maternal postpartum depressive (PPD) symptoms on maternal depressive symptoms in early childhood via parenting self-efficacy. Among a sample of 322 very low-income Mexican American mother-infant dyads (46% male infants), infant RSA was assessed at 6 weeks of age; mothers (M_age = 27.8, SD = 6.5) reported PPD symptoms every 3 weeks from 6 weeks to 6 months, parenting self-efficacy at 18 and 24 months, and depressive symptoms at 18 and 36 months. Higher PPD symptoms predicted higher maternal depressive symptoms at 36 months, especially among mothers whose infants had lower resting RSA. The interactive effect of PPD symptoms and infant RSA on 36-month depressive symptoms was partially mediated by lower parenting self-efficacy. Lower infant RSA may exacerbate the detrimental effects of PPD symptoms on subsequent maternal well-being via damage to mothers' beliefs in their ability to parent effectively.

Interplay of regional economic development, income, gender and type 2 diabetes: evidence from half a million Chinese

BACKGROUND

Following the rapid economic growth, there has been a strong disparity of regional development and personal income in China. Type 2 diabetes mellitus (T2DM) may be influenced by socioeconomic status at both the societal and individual levels. This study examines the associations of regional economic development, household income and gender on T2DM.

METHOD

Data from the baseline of a Chinese population-based study of approximately 500 000 adults from 10 areas were analysed. Clinically identified and screen-detected T2DM were examined. Regional economic development was indicated by gross domestic product (GDP) per capita. A logistic regression-based method was used to calculate the adjusted prevalence.

RESULT

The prevalence of T2DM was significantly higher in medium GDP per capita areas for both males (7.04%, 95% CI 6.82% to 7.26%) and females (6.04%, 95% CI 5.86% to 6.22%) compared with areas of other levels of economic development. The different shapes of associations between household income and T2DM prevalence were observed in different GDP per capita areas. There were strong gender differences in terms of both the trend and strength of association between household income and T2DM prevalence.

CONCLUSIONS

Findings from this study underscore the importance of economic conditions and gender difference on T2DM. It suggests that strategies for diabetes prevention should address social-economic differences besides a person-centred approach.

Neighbourhood disadvantage and depressive symptoms among adolescents followed into emerging adulthood

BACKGROUND

Residents of disadvantaged neighbourhoods report higher levels of depressive symptoms; however, few studies have employed prospective designs during adolescence, when depression tends to emerge. We examined associations of neighbourhood social fragmentation, income inequality and median household income with depressive symptoms in a nationally representative survey of adolescents.

METHODS

The NEXT Generation Health Study enrolled 10th-grade students from 81 US high schools in the 2009-2010 school year. Depressive symptoms were assessed with the Modified Depression Scale (wave 1) and the paediatric Patient-Reported Outcome Measurement Information System (waves 2-6). Neighbourhood characteristics at waves 1, 3, 4, and 5 were measured at the census tract level using geolinked data from the American Community Survey 5-year estimates. We used linear mixed models to relate neighbourhood disadvantage to depressive symptoms controlling for neighbourhood and individual sociodemographic factors.

RESULTS

None of the models demonstrated evidence for associations of social fragmentation, income inequality or median household income with depressive symptoms.

CONCLUSION

Despite the prospective design, repeated measures and nationally representative sample, we detected no association between neighbourhood disadvantage and depressive symptoms. This association may not exist or may be too small to detect in a geographically dispersed sample. Given the public health significance of neighbourhood effects, future research should examine the developmental timing of neighbourhood effects across a wider range of ages than in the current sample, consider both objective and subjective measures of neighbourhood conditions, and use spatially informative techniques that account for conditions of nearby neighbourhoods.

Income inequality and firearm homicide in the US: a county-level cohort study

Objective

Income inequality has been rising in the US and thought to be associated with violence especially homicide. About 75% of homicides involve firearms. We quantified the association between county-level income inequality and all-race/ethnicity and race/ethnicity-specific firearm homicide rates among individuals aged 14–39 years.

Methods

We conducted a cohort study of US counties to examine the association of Gini Index (ranging from 0 [perfect income equality] to 1.0 [perfect income inequality]) separately measured in 1990 and 2000 with all-race/ethnicity and race/ethnicity-specific firearm homicide rates in 2005–2015. Generalised linear mixed models with Poisson distribution including a random intercept for state provided IRRs and 95% CIs. Bayesian Poisson-lognormal hierarchical modelling with integrated nested Laplace approximations was used in exploratory spatial analyses. Models accounted for county-level age, sex and race/ethnicity composition, crime rate, deprivation, social capital, urbanicity, and firearm ownership.

Findings

The Gini Index was associated with firearm homicide rates among all races/ethnicities. After accounting for contextual determinants of firearm homicide, the association persisted among African–Americans. In this group, a 1 SD greater Gini Index in 1990 (IRR=1.09; 95% CI 1.02 to 1.16) and 2000 (IRR=1.09; 95% CI 1.01 to 1.17) was associated with greater firearm homicide rates in 2005–2015. Exploratory spatial analyses did not materially change the results.

Conclusion

Policies addressing the gap between the rich and the poor deserve further considerations for reducing firearm homicide rates. Incorporating income inequality to refine measures of socioeconomic position may advance public health and clinical research and practice for firearm violence prevention.

Migration and children's psychosocial development in China: When and why migration matters

Migration has affected a large number of children in many settings. Despite growing attention to these children, important gaps remain in our understanding of their psychosocial development, as well as the factors that mediate and moderate the impact of migration on children. The present study examines the influences of migration on children's psychosocial well-being in China using a new nationally representative survey. We compared different groups of children age 3-15, including migrant children, left-behind children, and rural and urban children in nonmigrant families. Results show that rural children left behind by both parents were significantly worse off in psychological and behavioral well-being than rural nonmigrant children. By contrast, rural children left behind by one parent and migrant children were no worse off. The disadvantage of left-behind children was mediated by their caregivers' emotional well-being and parenting practices. Frequent contact with migrant parents, but not receipt of remittances, helped ameliorate the vulnerability of left-behind children. These results add to our understanding of how migration affects child development in general.

Could Postnatal Women's Groups Be Used to Improve Outcomes for Mothers and Children in High-Income Countries? A Systematic Review

Introduction Participatory postnatal women’s groups have been shown to have a significant impact on maternal and neonatal mortality in low-income countries. However, it is not clear whether this approach can be translated to high-income countries (HICs). We conducted a systematic review to answer the question: “Can postnatal women’s groups improve health outcomes for mothers and children in high-income countries?” Methods MEDLINE, EMBASE and Cochrane databases were searched for randomised controlled trials testing any group-based intervention during the postnatal period, in HICs. No limitations were applied to stated outcomes. Results Nine trials, including 3029 women, fulfilled the criteria. Group-based interventions, facilitated by health professionals, ranged from didactic to participant-led. Three trials addressed postnatal depression, one addressed physical activity, whilst the remainder looked at multiple health or social outcomes. Three trials reported a significant association between their intervention and at least one outcome measure. Study limitations included poor and inequitable intervention uptake, low participant retention, small sample size and incomplete intervention description. Discussion This review found limited and incompletely described evidence testing the use of postnatal group-based interventions to improve health outcomes in HICs. Promising results were reported when the obstacles of sample size and group attendance were overcome. Studies reporting positive impacts on primary outcomes reported higher attendance rates and involved a psychoeducational or cognitive behavioural component in their group approaches. Further research should design and evaluate implementation strategies, assess the use of lay support workers in community settings to improve attendance and retention, and examine the effect of the group environment on outcomes.

Water insecurity and gendered risk for depression in rural Uganda: a hotspot analysis

Background

Water insecurity is linked to depression in low- and middle-income countries (LMICs), though it remains unclear how geospatial clustering of water insecurity in rural regions is associated with risk for depression.

Methods

We conducted a population-based survey of a rural parish in southwestern Uganda (N = 1603) to evaluate the joint geospatial clustering of water insecurity and risk for depression among men and women living in rural Uganda.

Results

Geospatial clustering of self-reported water insecurity and depressive symptoms was found to be present among both men and women. Depression hotspots were more often observed near water insecurity hotspots among women, relative to men. Multivariable regression revealed that residing in a water insecurity hotspot significantly increased risk for depressive symptoms among women, but not among men.

Conclusions

Residing in a water insecurity hotspot is associated with greater risk for probable depression among women, but not among men, pointing to the need for focused depression screening among women residing in water insecure households.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol

INTRODUCTION

Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration.

METHODS AND ANALYSIS

This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions.

ETHICS AND DISSEMINATION

This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.

Women's Health Policy in the United States: An American College of Physicians Position Paper

In this position paper, the American College of Physicians (ACP) examines the challenges women face in the U.S. health care system across their lifespans, including access to care; sex- and gender-specific health issues; variation in health outcomes compared with men; underrepresentation in research studies; and public policies that affect women, their families, and society. ACP puts forward several recommendations focused on policies that will improve the health outcomes of women and ensure a health care system that supports the needs of women and their families over the course of their lifespans.

Impact of Housing and Community Conditions on Multidimensional Health among Middle- and Low-Income Groups in Hong Kong

With decades of urbanization, housing and community problems (e.g., poor ventilation and lack of open public spaces) have become important social determinants of health that require increasing attention worldwide. Knowledge regarding the link between health and these problems can provide crucial evidence for building healthy communities. However, this link has heretofore not been identified in Hong Kong, and few studies have compared the health impact of housing and community conditions across different income groups. To overcome this gap, we hypothesize that the health impact of housing and community problems may vary across income groups and across health dimensions. We tested these hypotheses using cross-sectional survey data from Hong Kong. Several health outcomes, e.g., chronic diseases and the SF-12 v. 2 mental component summary scores, were correlated with a few types of housing and community problems, while other outcomes, such as the DASS-21⁻Stress scores, were sensitive to a broader range of problems. The middle- and low-income group was more severely affected by poor built environments. These results can be used to identify significant problems in the local built environment, especially amongst the middle- and low-income group.

Household income, income inequality, and health-related quality of life measured by the EQ-5D in Shaanxi, China: a cross-sectional study

Background

In advanced economies, economic factors have been found to be associated with many health outcomes, including health-related quality of life (HRQL), and people’s health is affected more by income inequality than by absolute income. However, few studies have examined the association of income inequality and absolute income with HRQL in transitional economies using individual data. This paper focuses on the effects of county or district income inequality and absolute income on the HRQL measured by EQ-5D and the differences between rural and urban regions in Shaanxi province, China.

Methods

Data were collected from the 2008 National Health Service Survey conducted in Shaanxi, China. The EQ-5D index based on Japanese weights was employed as a health indicator. The income inequality was calculated on the basis of self-reported income. The special requirements for complex survey data analysis were considered in the bivariate analysis and linear regression models.

Results

The mean of the EQ-5D index was 94.6. The EQ-5D index of people with low income was lower than that in the high-income group (for people in the rural region: 93.2 v 96.1, P < 0.01; for people in the urban region: 95.5 v 96.8, P < 0.01). Compared with people with moderate inequality, the EQ-5D index of those with high inequality was relatively lower (for people living in the rural region: 91.1 v 95.8, P < 0.01; for people living in the urban region: 95.6 v 97.3, P < 0.01). Adjusted by age, gender, education, marital status, employment, medical insurance, and chronic disease, all the coefficients of the low-income group and high income inequality were significantly negative. After stratifying by income group, all the effects of high income inequality remained negative in both income groups. However, the coefficients of the models in the high income group were not statistically significant.

Conclusion

Income inequality has damaging effects on HRQL in Shaanxi, China, especially for people with low income. In addition, people living in rural regions were more vulnerable to economic factors.

Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms

Most countries have witnessed a dramatic increase of income inequality in the past three decades. This paper addresses the question of whether income inequality is associated with the population prevalence of depression and, if so, the potential mechanisms and pathways which may explain this association. Our systematic review included 26 studies, mostly from high-income countries. Nearly two-thirds of all studies and five out of six longitudinal studies reported a statistically significant positive relationship between income inequality and risk of depression; only one study reported a statistically significant negative relationship. Twelve studies were included in a meta-analysis with dichotomized inequality groupings. The pooled risk ratio was 1.19 (95% CI: 1.07-1.31), demonstrating greater risk of depression in populations with higher income inequality relative to populations with lower inequality. Multiple studies reported subgroup effects, including greater impacts of income inequality among women and low-income populations. We propose an ecological framework, with mechanisms operating at the national level (the neo-material hypothesis), neighbourhood level (the social capital and the social comparison hypotheses) and individual level (psychological stress and social defeat hypotheses) to explain this association. We conclude that policy makers should actively promote actions to reduce income inequality, such as progressive taxation policies and a basic universal income. Mental health professionals should champion such policies, as well as promote the delivery of interventions which target the pathways and proximal determinants, such as building life skills in adolescents and provision of psychological therapies and packages of care with demonstrated effectiveness for settings of poverty and high income inequality.