Understanding Health Inequalities Research Capacities: Insights and Recommendations From Comparing Two High Income Settings.

Generating evidence on health inequalities (HI) is necessary to raise awareness of these issues, describe and monitor their evolution, analyze their causes, and inform interventions aiming to improve health equity. Yet not all cities and countries have the capacity to produce this type of research. Recent research provides new contextual and causal insights into this research production process, and in-depth understanding on why and how this type of research is produced in certain settings. This article aims to analyze two recent case studies that have uniquely explored this process in two high producers of HI research and high-income country settings to identify learning and distil recommendations, which may be insightful for other settings. Expanding and investing in this line of research is critical, particularly in places with lower HI research output and related capacity, in order to identify key contextual conditions and mechanisms that may enable or hinder this process. This new knowledge could guide the development of new HI research capacity strengthening strategies to foster this research in different settings, worldwide. More understanding is also needed on the relationship between HI research, policy, and action in order to tackle HI.

Tribute to Barbara Ehrenreich: Fighting for Labor Through Critical Research Journalism.

This is a short commentary to accompany the article "Hospital Workers: Class Conflicts in the Making" by Barbara Ehrenreich and John H. Ehrenreich. The article was originally published in the International Journal of Health Services in 1975. We are revisiting it in the current issue of the International Journal of Social Determinants of Health and Health Services due to its continued relevance and significance in the twenty-first Century.

Key epidemiological indicators and spatial autocorrelation patterns across five waves of COVID-19 in Catalonia.

This research studies the evolution of COVID-19 crude incident rates, effective reproduction number R(t) and their relationship with incidence spatial autocorrelation patterns in the 19 months following the disease outbreak in Catalonia (Spain). A cross-sectional ecological panel design based on n = 371 health-care geographical units is used. Five general outbreaks are described, systematically preceded by generalized values of R(t) > 1 in the two previous weeks. No clear regularities concerning possible initial focus appear when comparing waves. As for autocorrelation, we identify a wave's baseline pattern in which global Moran's I increases rapidly in the first weeks of the outbreak to descend later. However, some waves significantly depart from the baseline. In the simulations, both baseline pattern and departures can be reproduced when measures aimed at reducing mobility and virus transmissibility are introduced. Spatial autocorrelation is inherently contingent on the outbreak phase and is also substantially modified by external interventions affecting human behavior.

Social Inequalities in Mental Health and Self-Perceived Health in the First Wave of COVID-19 Lockdown in Latin America and Spain: Results of an Online Observational Study.

COVID-19 lockdowns greatly affected the mental health of populations and collectives. This study compares the mental health and self-perceived health in five countries of Latin America and Spain, during the first wave of COVID 19 lockdown, according to social axes of inequality. This was a cross-sectional study using an online, self-managed survey in Brazil, Chile, Ecuador, Mexico, Peru, and Spain. Self-perceived health (SPH), anxiety (measured through GAD-7) and depression (measured through PHQ-9) were measured along with lockdown, COVID-19, and social variables. The prevalence of poor SPH, anxiety, and depression was calculated. The analyses were stratified by gender (men = M; women = W) and country. The data from 39,006 people were analyzed (W = 71.9%). There was a higher prevalence of poor SPH and bad mental health in women in all countries studied. Peru had the worst SPH results, while Chile and Ecuador had the worst mental health indicators. Spain had the lowest prevalence of poor SPH and mental health. The prevalence of anxiety and depression decreased as age increased. Unemployment, poor working conditions, inadequate housing, and the highest unpaid workload were associated with worse mental health and poor SPH, especially in women. In future policies, worldwide public measures should consider the great social inequalities in health present between and within countries in order to tackle health emergencies while reducing the health breach between populations.

Why and how has the United Kingdom become a high producer of health inequalities research over the past 50 years? A realist explanatory case study.

BACKGROUND: Evidence on health inequalities has been growing over the past few decades, yet the capacity to produce research on health inequalities varies between countries worldwide and needs to be strengthened. More in-depth understanding of the sociohistorical, political and institutional processes that enable this type of research and related research capacity to be generated in different contexts is needed. A recent bibliometric analysis of the health inequalities research field found inequalities in the global production of this type of research. It also found the United Kingdom to be the second-highest global contributor to this research field after the United States. This study aims to understand why and how the United Kingdom, as an example of a "high producer" of health inequalities research, has been able to generate so much health inequalities research over the past five decades, and which main mechanisms might have been involved in generating this specific research capacity over time. METHODS: We conducted a realist explanatory case study, which included 12 semi-structured interviews, to test six theoretical mechanisms that we proposed might have been involved in this process. Data from the interviews and grey and scientific literature were triangulated to inform our findings. RESULTS: We found evidence to suggest that at least four of our proposed mechanisms have been activated by certain conditions and have contributed to the health inequalities research production process in the United Kingdom over the past 50 years. Limited evidence suggests that two new mechanisms might have potentially also been at play. CONCLUSIONS: Valuable learning can be established from this case study, which explores the United Kingdom's experience in developing a strong national health inequalities research tradition, and the potential mechanisms involved in this process. More research is needed to explore additional facilitating and inhibiting mechanisms and other factors involved in this process in this context, as well as in other settings where less health inequalities research has been produced. This type of in-depth knowledge could be used to guide the development of new health inequalities research capacity-strengthening strategies and support the development of novel approaches and solutions aiming to tackle health inequalities.

Why Social (Political, Economic, Cultural, Ecological) Determinants of Health? Part 1: Background of a Contested Construct.

This article is the first half of a 2-part essay on the Social Determinants of Health (SDOH) as a field of scientific inquiry and theoretical framework, exploring its historical roots, current applications, and the controversies that surround it. Part 1 (this article) discusses the background and rationale of the SDOH framework, whilst part 2 (forthcoming) will analyze the current alternatives to this framework. The authors analyze the debate surrounding the contested term "social" in the field of health equity, through a clarification of the terms "social" and "social systems" and providing an alternative model through realist semantics and ethics. Despite the misunderstandings of the term "social," the authors argue that SDOH remains a useful umbrella term to capture the political, economic, cultural, and ecological determinants of health. Through this essay, the authors outline the reasons behind our decision to change this journal's title from International Journal of Health Services to International Journal of Social Determinants of Health and Health Services.

The double burden of precariousness: linking housing, employment, and perceived stress - a cross-sectional study.

Employment precariousness is widely recognised as a social determinant of health and a chronic stressor. Yet precariousness extends beyond employment, into other aspects of life. Using a multidimensional social pathways approach, this study examines the synergistic effects of employment and housing precariousness on self-perceived stress. This study uses the PRESSED dataset (N = 255) derived from the Barcelona Health Survey, which collects data on stress using the Perceived Stress Scale (PSS). Employment precariousness was operationalized using the Employment Precariousness Scale (EPRES) and a multidimensional indicator of housing precariousness was constructed. Generalized structural equation modelling was used to estimate associations between these indicators and self-perceived stress measured by Perceived Stress Survey (PSS), after accounting for sociodemographic variables. Employment and housing precariousness were positively associated with self-perceived stress (OR = 3.23 ; p = 0.002) (OR = 4.28 ; p = 0.065) respectively. The mediating effect of housing precariousness accounted for 16% of the total effect of employment precariousness on stress after controlling for sociodemographic variables. Furthermore, we find that both precarious conditions were unequally distributed by age, sex educational level, and place of birth in the sample. We conclude that employment and housing precariousness are important chronic stressors and that a social pathway approach is needed.

Impact of COVID-19 inequalities on children: An intersectional analysis.

Societal concerns about the effects of the COVID-19 pandemic have largely focussed on the social groups most directly affected, such as the elderly and health workers. However, less focus has been placed on understanding the effects on other collectives, such as children. While children's physical health appears to be less affected than the adult population, their mental health, learning and wellbeing is likely to have been significantly negatively affected during the pandemic due to the varying policy restrictions, such as withdrawal from face to face schooling, limited peer-to-peer interactions and mobility and increased exposure to the digital world amongst other things. Children from vulnerable social backgrounds, and especially girls, will be most negatively affected by the impact of COVID-19, given their different intersecting realities and the power structures already negatively affecting them. To strengthen the understanding of the social determinants of the COVID-19 crisis that unequally influence children's health and wellbeing, this article presents a conceptual framework that considers the multiple axes of inequalities and power relations. This understanding can then be used to inform analyses and impact assessments, and in turn inform the development of effective and equitable mitigation strategies as well as assist to be better prepared for future pandemics.

Are Women's Empowerment and Income Inequality Associated with Excess Weight in Latin American Cities?

While income gradients and gender inequalities in excess weight have been noted elsewhere, data from Latin American cities is lacking. We analyzed gender-specific associations between city-level women's empowerment and income inequality with individual-level overweight/obesity, assessing how these associations vary by individual education or living conditions within cities in Latin America. Data came from national surveys and censuses, and was compiled by the SALURBAL project (Urban Health in Latin America). The sample included 79,422 individuals (58.0% women), living in 538 sub-cities, 187 cities, and 8 countries. We used gender-stratified Poisson multilevel models to estimate the Prevalence Rate Ratios (PRR) for overweight/obesity (body mass index ≥ 25 kg/m2) per a unit change in city-level women's empowerment (proxied by a score that measures gender inequalities in employment and education) and income inequality (proxied by income-based Gini coefficient). We also tested whether individual education or sub-city living conditions modified such associations. Higher city labor women's empowerment (in women) and higher city Gini coefficient (in men) were associated with a lower prevalence of overweight/obesity (PRR = 0.97 (95%CI 0.94, 0.99) and PRR = 0.94 (95%CI 0.90, 0.97), respectively). The associations varied by individual education and sub-city living conditions. For labor women's empowerment, we observed weakened associations towards the null effect in women with lower education and in residents of sub-cities with worse living conditions (men and women). For the Gini coefficient, the association was stronger among men with primary education, and a negative association was observed in women with primary education. Our findings highlight the need for promoting equity-based policies and interventions to tackle the high prevalence of excess weight in Latin American cities.

Deaths of Despair: A Scoping Review on the Social Determinants of Drug Overdose, Alcohol-Related Liver Disease and Suicide.

BACKGROUND: There is a lack of consensus on the social determinants of Deaths of Despair (DoD), i.e., an increase in mortality attributed to drug overdose, alcohol-related liver disease, and suicide in the United States (USA) during recent years. The objective of this study was to review the scientific literature on DoD with the purpose of identifying relevant social determinants and inequalities related to these mortality trends. METHODS: Scoping review focusing on the period 2015-2022 based on PubMed search. Articles were selected according to the following inclusion criteria: published between 1 January 2000 and 31 October 2021; including empirical data; analyzed DoD including the three causes defined by Case and Deaton; analyzed at least one social determinant; written in English; and studied DoD in the USA context only. Studies were excluded if they only analyzed adolescent populations. We synthesized our findings in a narrative report specifically addressing DoD by economic conditions, occupational hazards, educational level, geographical setting, and race/ethnicity. RESULTS: Seventeen studies were included. Overall, findings identify a progressive increase in deaths attributable to suicide, drug overdose, and alcohol-related liver disease in the USA in the last two decades. The literature concerning DoD and social determinants is relatively scarce and some determinants have been barely studied. However different, however, large inequalities have been identified in the manner in which the causes of death embedded in the concept of DoD affect different subpopulations, particularly African American, and Hispanic populations, but blue collar-whites are also significantly impacted. Low socioeconomic position and education levels and working in jobs with high insecurity, unemployment, and living in rural areas were identified as the most relevant social determinants of DoD. CONCLUSIONS: There is a need for further research on the structural and intermediate social determinants of DoD and social mechanisms. Intersectional and systemic approaches are needed to better understand and tackle DoD and related inequalities.

Arms, Conventional Wisdom, and Public Health Prevention.

Every year, 8 million small arms and 15 billion rounds of ammunition are manufactured in the world. Every day, 700 people worldwide (more than 2.5 million in a decade) die from firearms such as pistols, shotguns, assault rifles, or machine guns. Between 1968 and 2011, there were 1.4 million gun-related deaths in the United States (including suicides, homicides, and accidents) compared with 1.2 million North American deaths in all wars. This article looks at the historic and cultural context that has generated and shaped the U.S.'s "gun culture" and prevailing mentality regarding the right to bear arms, critiquing the vision that such a pro-arms mentality is an intrinsic and unchangeable element of U.S. culture. It exposes the neoliberal roots of the current U.S. gun violence epidemic, asking the question of "why?" in order to move toward an alternative conventional wisdom and overcome this urgent public health crisis in the U.S. and elsewhere.

Applying an equity lens to liver health and research in Europe.

Liver disease is a major cause of premature death and disability in Europe. However, morbidity and mortality are not equally distributed in the population. In spite of this, there are few studies addressing the issue of health inequalities in Europe. In this Public Health Corner article, we compare the research conducted on health inequalities in Europe to other settings and highlight the main differences based upon an extensive review of the literature. We report that only 10.2% of studies were led by European institutions or conducted in European populations and that certain topics such as alcohol-related liver disease are largely overlooked. In addition, we discuss the relevance of including a health equity lens when conducting clinical, epidemiological and health systems' research in liver disease and set out the basic requirements to tackle health inequalities in liver disease in Europe.

Inequalities in COVID-19 inequalities research: Who had the capacity to respond?

The COVID-19 pandemic has been testing countries' capacities and scientific preparedness to actively respond and collaborate on a common global threat. It has also heightened awareness of the urgent need to empirically describe and analyze health inequalities to be able to act effectively. In turn, this raises several important questions that need answering: What is known about the rapidly emerging COVID-19 inequalities research field? Which countries and world regions have been able to rapidly produce research on this topic? What research patterns and trends have emerged, and how to these compared to the (pre-COVID-19) global health inequalities research field? Which countries have been scientifically collaborating on this important topic? Where are the scientific knowledge gaps, and indirectly where might research capacities need to be strengthened? In order to answer these queries, we analyzed the global scientific production (2020-2021) on COVID-19 associated inequalities by conducting bibliometric and network analyses using the Scopus database. Specifically, we analyzed the volume of scientific production per country (via author affiliations), its distribution by country income groups and world regions, as well as the inter-country collaborations within this production. Our results indicate that the COVID-19 inequalities research field has been highly collaborative; however, a number of significant inequitable research practices exist. When compared to the (pre-COVID-19) global health inequalities research field, similar inequalities were identified, however, several new dynamics and partnerships have also emerged that warrant further in-depth exploration. To ensure preparedness for future crises, and effective strategies to tackle growing social inequalities in health, investment in global health inequalities research capacities must be a priority for all.

Effectiveness of an Energy-Counseling Intervention in Reducing Energy Poverty: Evidence from a Quasi-Experimental Study in a Southern European City.

Energy poverty is a serious social problem with well-known adverse health consequences. This problem has been addressed mainly through improvements in the energy efficiency of housing. Still, little is known about the effects of information-based measures on energy poverty and their impacts on health. A quasi-experimental study was implemented to assess the effectiveness of an energy-counseling home visit intervention targeting the vulnerable population in a southern European city, Barcelona, in alleviating energy poverty and improving health. The intervention had beneficial impacts on keeping homes at an adequate indoor temperature and reducing primary care visits. No effects were found on self-perceived health or self-reported anxiety and depression. After the intervention, participants reported a decrease in arrears on utility bills, but less pronounced than in the comparison group. In conclusion, the study showed that information-based measures lead to psychosocial gains and reduced healthcare use. Nevertheless, the impact of these measures could be enhanced by combining them with policies and programmes that address the structural determinants of energy poverty.

Precarious Employment and Chronic Stress: Do Social Support Networks Matter?

Precarious employment has been identified as a potentially damaging stressor. Conversely, social support networks have a well-known protective effect on health and well-being. The ways in which precariousness and social support may interact have scarcely been studied with respect to either perceived stress or objective stress biomarkers. This research aims to fill this gap by means of a cross-sectional study based on a non-probability quota sample of 250 workers aged 25-60 in Barcelona, Spain. Fieldwork was carried out between May 2019 and January 2020. Employment precariousness, perceived social support and stress levels were measured by means of scales, while individual steroid profiles capturing the chronic stress suffered over a period of a month were obtained from hair samples using a liquid chromatography-tandem mass spectrometry methodology. As for perceived stress, analysis indicates that a reverse buffering effect exists (interaction B = 0.22, p = 0.014). Steroid biomarkers are unrelated to social support, while association with precariousness is weak and only reaches significance at p < 0.05 in the case of women and 20ß dihydrocortisone metabolites. These results suggest that social support can have negative effects on the relationship between perceived health and an emerging stressful condition like precariousness, while its association with physiological measures of stress remains uncertain.

What do we know about the impact of economic recessions on mortality inequalities? A critical review.

Historically, there has been a debate on the effects of recessions on population health, and especially on mortality and its distribution across different social groups. This paper contributes to this discussion by means of a critical review of the research on the impact of economic recessions on mortality inequalities in the period 1980-2020. We analyzed 19 studies according to their mortality outcomes, socioeconomic indicators, design, analysis, and main findings. Twelve studies focused on European countries or urban areas, two on Asian countries, two on Russia, one on Asia and Europe, one on the USA, and one in Somalia. Five articles included cross-country comparisons (four between European countries or cities and one between Asian and European countries). The Great Recession of 2008 was the most researched economic crisis, followed by country-specific crises in the 90s, the fall of the Soviet Union, and some crises during the 80s. Most studies (n = 15) showed an overall or partial increase in mortality inequalities after an economic recession. However, two papers found a decrease in mortality inequalities due to the worsening of the health of the upper and middle classes, one article found a decrease in inequalities due to a general improvement in population health, and a study found a "slow-down" effect of pre-existent mortality inequalities.