A Brief Tool to Screen Patients for Precarious Employment: A Validation Study.

PURPOSE: Precarious employment, defined by temporary contracts, unstable employment, or job insecurity, is increasingly common and is associated with inconsistent access to benefits, lower income, and greater exposure to physical and psycholosocial hazards. Clinicians can benefit from a simple approach to screen for precarious employment to improve their understanding of a patient's social context, help with diagnoses, and inform treatment plans and intersectional interventions. Our objective was to validate a screening tool for precarious employment. METHODS: We used a 3-item screening tool that covered key aspects of precarious employment: non-standard employment, variable income, and violations of occupational health and safety rights and protections. Answers were compared with classification using the Poverty and Employment Precarity in Southern Ontario Employment Index. Participants were aged 18 years and older, fluent in English, and employed. They were recruited in 7 primary care clinic waiting rooms in Toronto, Canada over 12 months. RESULTS: A total of 204 people aged 18-72 years (mean 38 [SD 11.3]) participated, of which 93 (45.6%) identified as men and 119 (58.3%) self-reported as White. Participants who reported 2 or more of the 3 items as positive were almost 4 times more likely to be precariously employed (positive likelihood ratio = 3.84 [95% CI, 2.15-6.80]). CONCLUSIONS: A 3-item screening tool can help identify precarious employment. Our tool is useful for starting a conversation about employment precarity and work conditions in clinical settings. Implementation of this screening tool in health settings could enable better targeting of resources for managing care and connecting patients to legal and employment support services.

Tools for local health in all policies implementation: evidence from an explanatory case study of Kuopio, Finland.

AIMS: This paper describes the use of three governance tools for health in all policies utilised to facilitate implementation in the municipality of Kuopio, Finland: impact assessments, a city mandate (the Kuopio strategy), and shared budgets. METHODS: An explanatory case study was used. Data sources included semistructured interviews with 10 government employees and scholarly literature. Realist scientific methods were used to reveal mechanisms underlying the use of tools in health in all policies. RESULTS: Strong evidence was found supporting initial and new theory/hypotheses regarding the use of each tool in achieving positive implementation outcomes. Impact assessments facilitated health in all policies by enhancing understanding of health implications. The Kuopio strategy aided in implementation by giving credence to health in all policies work via formal authority. Shared budgets promoted intersectoral discussions and understanding, and a sense of ownership, in addition to allowing time to be spent on health in all policies work and not financial deliberation. CONCLUSIONS: Findings confirm the efficacious use of three governance tools in implementing health in all policies in Kuopio. Knowledge and evidence-based guidelines on local health in all policies implementation are needed as this policy approach continues to be recognised and adopted as a means to promote population health and health equity.

How and why buy-in for health in all policies was facilitated in Ecuador: a realist case study of Plan Nacional para el Buen Vivir.

BACKGROUND: In 2008, Ecuador introduced Plan Nacional para el Buen Vivir (PNBV; National Plan for Good Living), which was widely recognized as a promising example of Health in All Policies (HiAP) due to the integration of policy sectors on health and health equity objectives. PBNV was implemented through three successive plans (2009-2013, 2013-2017, 2017-2021). In a time of widening global health inequities, there is growing interest in understanding how politics and governance shape HiAP implementation. The objective of this study was to test specific hypotheses about how, why, to what extent, and under what circumstances HiAP was implemented in Ecuador. METHODS: An explanatory case study approach (HiAP Analysis using Realist Methods on International Case Studies-HARMONICS) was used to understand the processes that hindered or facilitated HiAP implementation. Realist methods and systems theory were employed to test hypotheses through analysis of empirical and grey literature, and 19 key informant interviews. This case study focused on processes related to buy-in for a HiAP approach by diverse policy sectors, particularly in relation to the strong mandate and transformative governance approach that were introduced by then-President Rafael Correa's administration to support PNBV. RESULTS: The mandate and governance approach of the HiAP approach achieved buy-in for implementation across diverse sectors. Support for the hypotheses was found through direct evidence about buy-in for HiAP implementation by policy sectors; and indirect evidence about allocation of governmental resources for HiAP implementation. Key mechanisms identified included: influence of political elites; challenges in dealing with political opposition and 'siloed' ways of thinking; and the role of strategies and resources in motivating buy-in. CONCLUSION: In Ecuador, political elites were a catalyst for mechanisms that impacted buy-in and government funding for HiAP implementation. They raised awareness among policy sectors initially opposed to PNBV about the rationale for changing governance practices, and they provided financial resources to support efforts related to PNBV. Specific mechanisms help explain these phenomena further. Future studies should examine ways that PNBV may have been an impediment to health equity for some marginalized groups while strengthening HiAP implementation.

Who loses more? Identifying the relationship between hospitalization and income loss: prediction of hospitalization duration and differences of gender and employment status.

BACKGROUND: The major determinants of health and well-being include wider socio-economic and political responses to poverty alleviation. To data, however, South Korea has no related social protection policies to replace income loss or prevent non-preferable health conditions for workers. In particular, there are several differences in social protection policies by gender or occupational groups. This study aimed to investigate how hospitalization affects income loss among workers in South Korea. METHODS: The study sample included 4876 Korean workers who responded to the Korean Welfare Panel Study (KoWePS) for all eight years from 2009 to 2016. We conducted a receiver operating characteristics (ROC) analysis to determine the cut-off point for the length of hospitalization that corresponded to the greatest loss of income. We used panel multi-linear regression to examine the relationship between hospitalization and income loss by gender and employment arrangement. RESULTS: The greatest income loss for women in non-standard employment and self-employed men was observed when the length of hospitalization was seven days or less. When they were hospitalized for more than 14 days, income loss also occurred among men in non-standard employment. In addition, when workers were hospitalized for more than 14 days, the impact of the loss of income was felt into the subsequent year. CONCLUSION: Non-standard and self-employed workers, and even female standard workers, are typically excluded from public insurance coverage in South Korea, and social security is insufficient when they are injured. To protect workers from the vicious circle of the poverty-health trap, national social protections such as sickness benefits are needed.

Precarious employment and mental health across European welfare states: a gender perspective.

OBJECTIVE: The aim of this article was to examine the relationship between precarious employment (PE), welfare states (WS) and mental health in Europe from a gender perspective. METHODS: Data were derived from the European Working Conditions Survey 2015. PE was measured through the Employment Precariousness Scale for Europe (EPRES-E), validated for comparative research in 22 European countries, and categorized into quartiles. Countries were classified into Continental, Anglo-Saxon, Scandinavian, Southern and Central-Eastern WS. Mental health was assessed through the WHO-5 Well-Being Index and dichotomized into poor and good mental health. In a sample of 22,555 formal employees, we performed gender-stratified multi-level logistic regression models. RESULTS: Results showed greater prevalences of PE and poor mental health among women. However, the association between them was stronger among men. Cross-country differences were observed in multi-level regressions, but the interaction effect of WS was only significant among women. More precisely, Central-Eastern WS enhanced the likelihood of poor mental health among women in high precarious employment situations (quartiles 3 and 4). CONCLUSIONS: These findings suggest the interaction between contextual and individual factors in the production of mental health inequalities, both within and across countries. They also call for the incorporation of gender-sensitive welfare policies if equitable and healthy labor markets are to be achieved in Europe.

The impact of changes in job security on mental health across gender and family responsibility: evidence from the UK Household Longitudinal Study.

PURPOSE: While there is strong evidence that job insecurity leads to mental distress, little is known about how gender and parental responsibilities may exacerbate this relationship. Examining their contribution as potential effect modifiers may provide insights into gender inequalities in mental health and inform gender-sensitive labour policies to ameliorate the negative effects of job insecurity. Our study addresses this gap by examining the longitudinal association between job insecurity and mental health across different configurations of gender and parental responsibilities. METHODS: Our sample includes 34,772 employed participants over the period of 2010-2018. A gender-stratified fixed-effect regression was used to model the within-person change over time in mental health associated with loss of job security, and effect modification by parent-partner status (e.g. childfree men, partnered father, etc.). RESULTS: Loss of job security was associated with a moderate decrease in mental health functioning for partnered fathers, partnered mothers, and childfree men and women ranging between a reduction in MCS-12 by 1.00 to 2.27 points (p < 0.05). Lone fathers who lose their job security experienced a higher decrease in mental health functioning at - 7.69 (95% CI - 12.69 to - 2.70), while lone mothers did not experience any change. CONCLUSION: The effects of job insecurity on mental health is consistent across gender and parent-partner status with the exception of lone fathers and lone mothers. Future studies should investigate the effects of policies that may reduce mental distress in the face of the threat of job loss such as reducing wait time for payment of unemployment benefits.

Free agents or cogs in the machine? Classed, gendered, and racialized inequities in hazardous working conditions.

INTRODUCTION: Few epidemiologic studies have used relational social class measures based on control over productive assets and others' labor to analyze inequities in health-affecting working conditions. Moreover, these studies have often neglected the gendered and racialized dimensions of class relations, dimensions which are essential to understanding population patterns of health inequities. Our study fills these gaps. METHODS: Using data from the 2002-2018 U.S. General Social Survey, we assigned respondents to the worker, manager, petit bourgeois, or capitalist classes based on their supervisory authority and self-employment status. Next, we estimated class, class-by-gender, and class-by-race inequities in compensation/safety, the labor process, control, and conflict, using Poisson models. We also estimated gender-by-race inequities among workers. RESULTS: We identified substantial class inequities, with worse conditions for workers, which is the largest class within genders and racialized groups, but also disproportionately consists of women and people of color (POC), particularly women of color (WOC). For example, relative to workers, capitalists were less likely to report that safety is not a priority (prevalence ratio [PR]: 0.41, 95% confidence interval [CI]: 0.21, 0.82), repetitive tasks (PR: 0.36, 95% CI: 0.21, 0.61), and lacking freedom (PR: 0.11, 95% CI: 0.05, 0.24). We also identified inequities among workers, with women and POC, particularly WOC, reporting worse conditions than white male workers, especially greater discrimination/harassment (WOC PR: 1.70, 95% CI: 1.36, 2.13). CONCLUSION: We identified substantial inequities in working conditions across intersecting classes, genders, and racialized groups. These inequities threaten workers' health, particularly among women and POC.

Collecting occupation and hazards information in primary care using O*NET.

OBJECTIVE: The objective of this study was to determine the feasibility of collecting occupation and occupational hazard data in a primary care setting, using the Occupational Information Network (O*NET) database to assist with classification. METHODS: We collected data from 204 employed adult primary care patients in Toronto, Canada, on their occupation and exposure to occupational hazards, and mapped their job titles to the O*NET database. We compared their self-reported occupational hazard exposures with the likelihood of exposure on O*NET. RESULTS: Exposure to repetitive arm movement was reported by 78%, to vapors/gas/dust/fumes by 30%, to noise by 30%, and to heavy loads by 31%. Significant differences in exposure to vapors/gas/dust/fumes were associated with work precarity. We matched the majority of job titles (89%) to O*NET categories. CONCLUSIONS: Collecting employment information in primary care setting was feasible, with the majority of job titles mapping onto O*NET classifications.

Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

The Serpent of Their Agonies: Exploitation as Structural Determinant of Mental Illness.

BACKGROUND: Social stratification is a well-documented determinant of mental health. Traditional measures of stratification (e.g., socioeconomic status) reduce dynamic social processes to individual attributes downstream of mechanisms that generate stratification. In this study, we measure one process theorized to generate and reproduce social stratification-economic exploitation-and explore its association with mental health. METHODS: Data are from the 1983 to 2017 waves of the Panel Study of Income Dynamics, a nationally representative cohort study (baseline N = 3059). We operationalized "unconcealed exploitation" as the percentage of individuals' labor income they were hypothetically not paid for productive hours. We ascertained psychologic distress and mental illness with the Kessler-6 (K6) scale. RESULTS: We fit inverse probability-weighted marginal structural models and found that for each unit increase in unconcealed exploitation, psychologic distress increased by 1.6 points (95% confidence interval = 0.71, 2.5) on the K6 scale and the odds of mental illness tripled (odds ratio = 3.0, 95% confidence interval = 1.5, 6.1). Results were not driven entirely by overwork and were robust to different inverse probability-weighted estimation strategies and sensitivity analyses. CONCLUSIONS: Exploitation is associated with mental illness. Focusing on exploitation rather than its consequences (e.g., socioeconomic status), shifts attention to a structural process that may be a more appropriate explanatory mechanism, and a more pragmatic intervention target, for mental illness.

Experiences of everyday racism in Toronto's health care system: a concept mapping study.

BACKGROUND: In Canada, there is longstanding evidence of health inequities for racialized groups. The purpose of this study is to understand the effect of current health care policies and practices on racial/ethnic groups and in particular racialized groups at the level of the individual in Toronto's health care system. METHODS: This study used a semi-qualitative study design: concept mapping. A purposive sampling strategy was used to recruit participants. Health care users and health care providers from Toronto and the Greater Toronto Area participated in all four concept mapping activities. The sample sizes varied according to the activity. For the rating activity, 41 racialized health care users, 23 non-racialized health care users and 11 health care providers completed this activity. The data analysis was completed using the concept systems software. RESULTS: Participants generated 35 unique statements of ways in which patients feel disrespect or mistreatment when receiving health care. These statements were grouped into five clusters: 'Racial/ethnic and class discrimination', 'Dehumanizing the patient', 'Negligent communication', 'Professional misconduct', and 'Unequal access to health and health services'. Two distinct conceptual regions were identified: 'Viewed as inferior' and 'Unequal medical access'. From the rating activity, racialized health care users reported 'race'/ethnic based discrimination or everyday racism as largely contributing to the challenges experienced when receiving health care; statements rated high for action/change include 'when the health care provider does not complete a proper assessment', 'when the patient's symptoms are ignored or not taken seriously', 'and 'when the health care provider belittles or talks down to the patient'. CONCLUSIONS: Our study identifies how racialized health care users experience everyday racism when receiving health care and this is important to consider in the development of future research and interventions aimed at addressing institutional racism in the health care setting. To support the elimination of institutional racism, anti-racist policies are needed to move beyond cultural competence polices and towards addressing the centrality of unequal power social relations and everyday racism in the health care system.

Participation of women in the health workforce in the fragile and conflict-affected countries: a scoping review.

INTRODUCTION AND BACKGROUND: The full participation of women as healthcare providers is recognized globally as critical to favorable outcomes at all levels, including the healthcare system, to achieving universal health coverage and sustainable development goals (SDGs) by 2030. However, systemic challenges, gender biases, and inequities exist for women in the global healthcare workforce. Fragile and conflict-affected states/countries (FCASs) experience additional pressures that require specific attention to overcome challenges and disparities for sustainable development. FCASs account for 42% of global deaths due to communicable, maternal, perinatal, and nutritional conditions, requiring an appropriate health workforce. Consequently, there is a need to understand the impact of gender on workforce participation, particularly women in FCASs. METHODS: This scoping review examined the extent and nature of existing literature, as well as identified factors affecting women's participation in the health workforce in FCASs. Following Arksey and O'Malley's scoping review methodology framework, a systematic search was conducted of published literature in five health sciences databases and grey literature. Two reviewers independently screened the title and abstract, followed by a full-text review for shortlisted sources against set criteria. RESULTS: Of 4284, 34 sources were reviewed for full text, including 18 primary studies, five review papers, and 11 grey literature sources. In most FCASs, women predominate in the health workforce, concentrated in nursing and midwifery professions; medicine, and the decision-making and leadership positions, however, are occupied by men. The review identified several constraints for women, related to professional hierarchies, gendered socio-cultural norms, and security conditions. Several sources highlight the post-conflict period as a window of opportunity to break down gender biases and stereotypes, while others highlight drawbacks, including influences by consultants, donors, and non-governmental organizations. Consultants and donors focus narrowly on programs and interventions solely serving women's reproductive health rather than taking a comprehensive approach to gender mainstreaming in planning human resources during the healthcare system's restructuring. CONCLUSION: The review identified multiple challenges and constraints facing efforts to create gender equity in the health workforce of FCASs. However, without equal participation of women in the health workforce, it will be difficult for FCASs to make progress towards achieving the SDG on gender equality.

State-society nexus in Brazil and Venezuela and its effect on participatory governance efforts in health and other sectors.

INTRODUCTION: Participatory governance is about state and society jointly responsible for political decisions and services. The origins and trajectory of participatory governance initiatives are determined by the socio-political context and specifically the nature of state-society relations. Participation by communities in health interventions has been promoted globally as a strategy to involve citizens in health decision-making but with little success. Such participatory governance in health should be seen not as a strategy alone but as a political project in which organized communities challenge the status-quo in health. METHODS: This paper deals with the wider socio-political context of participatory governance initiatives. It uses comparative politics literature to analyze socio-political context in Brazil and Venezuela, historically spanning half century prior to 2015, to assess whether it was conducive to participatory governance. The focus of this paper's analysis particularly is on the socio-political changes that were taking place in Brazil and Venezuela in the decades of the 1980s and 1990s. Those decades formed the bedrock on which the two countries experienced democratization and a socialist transformation that has lasted well into the first decade of the twenty-first century. The situation in the health sector is also described for the two countries showing a parallel trajectory to the wider political context and that reflected the political ideology. For this assessment, we use a contemporary framework called the 'socialist compass' which links dynamics of power relations in various ways among three domains of power, namely, state power, economic power, and social power. Socialist compass can be used to assess whether such reforms are moving towards or against social empowerment. CONCLUSION: Our analysis reveals that both Brazil and Venezuela were moving in the direction of social empowerment until at least the year 2015, just before the political turmoil started engulfing the left-leaning regimes in both the countries.

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review.

CONTEXT: Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. OBJECTIVES: A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. DESIGN: A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. ELIGIBILITY CRITERIA: Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing stability, physical and mental health outcomes, and health care utilization. RESULTS: Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. CONCLUSIONS: Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

Mental illness, drinking, and the social division and structure of labor in the United States: 2003-2015.

BACKGROUND: We draw on a relational theoretical perspective to investigate how the social division and structure of labor are associated with serious and moderate mental illness and binge and heavy drinking. METHODS: The Panel Study of Income Dynamics and the Occupational Information Network were linked to explore how occupation, the productivity-to-pay gap, unemployment, the gendered division of domestic labor, and factor-analytic and theory-derived dimensions of work are related to mental illness and drinking outcomes. RESULTS: Occupations involving manual labor and customer interaction, entertainment, sales, or other service-oriented labor were associated with increased odds of mental illness and drinking outcomes. Looking for work, more hours of housework, and a higher productivity-to-pay gap were associated with increased odds of mental illness. Physical/risky work was associated with binge and heavy drinking and serious mental illness; technical/craft work and automation were associated with binge drinking. Work characterized by higher authority, autonomy, and expertise was associated with lower odds of mental illness and drinking outcomes. CONCLUSIONS: Situating work-related risk factors within their material context can help us better understand them as determinants of mental illness and identify appropriate targets for social change.

Anxiety and contradictory class position in the hierarchy of Brazilian firefighters.

BACKGROUND: Workers holding intermediate hierarchical positions in an institution may have a higher risk of occupational stress-related, ill health. This study examined the prevalence rates and odds ratios (ORs) of anxiety disorders among a hierarchical group of firefighters. METHODS: This cross-sectional study samples firefighters from Minas Gerais, Brazil, who answered a structured questionnaire in 2011 (survey completion rate = 89.5%). The outcome of interest was a medical diagnosis of anxiety disorder. Bivariate and multivariate analyses were conducted among five hierarchical occupational positions: privates (lowest position), corporals, sergeants (intermediate position), sub lieutenants, and officers (highest position). RESULTS: Overall, 8.4% of the sample reported an anxiety disorder, with the highest rate observed among intermediate workers (sergeants = 14.2%), followed by corporals (10%), privates (5.6%), sub lieutenants (5%), and officers (2.1%). Compared with privates, the unadjusted OR for sergeants was 2.49 (95% confidence interval, 1.35, 4.58). This finding remained statistically significant after adjustment for several control variables but was eliminated by age. CONCLUSION: The mental health of firefighters is affected by social class position. Mental health promotion efforts should focus on longitudinal research and work toward interventions aimed at modifying the hierarchical structure of workplaces.

How and why do win-win strategies work in engaging policy-makers to implement Health in All Policies? A multiple-case study of six state- and national-level governments.

BACKGROUND: Much of the research about Health in All Policies (HiAP) implementation is descriptive, and there have been calls for more evaluative evidence to explain how and why successes and failures have occurred. In this cross-case study of six state- and national-level governments (California, Ecuador, Finland, Norway, Scotland and Thailand), we tested hypotheses about win-win strategies for engaging policy-makers in HiAP implementation drawing on components identified in our previous systems framework. METHODS: We used two sources of data - key informant interviews and peer-reviewed and grey literature. Using a protocol, we created context-mechanism-outcome pattern configurations to articulate mechanisms that explain how win-win strategies work and fail in different contexts. We then applied our evidence for all cases to the systems framework. We assessed the quality of evidence within and across cases in terms of triangulation of sources and strength of evidence. We also strengthened hypothesis testing using replication logic. RESULTS: We found robust evidence for two mechanisms about how and why win-win strategies build partnerships for HiAP implementation - the use of shared language and the value of multiple outcomes. Within our cases, the triangulation was strong, both hypotheses were supported by literal and contrast replications, and there was no support against them. For the third mechanism studied, using the public-health arguments win-win strategy, we only found evidence from Finland. Based on our systems framework, we expected that the most important system components to using win-win strategies are sectoral objectives, and we found empirical support for this prediction. CONCLUSIONS: We conclude that two mechanisms about how and why win-win strategies build partnerships for HiAP implementation - the use of shared language and the value of multiple outcomes - were found as relevant to the six settings. Both of these mechanisms trigger a process of developing synergies and releasing potentialities among different government sectors and these interactions between sectors often work through sectoral objectives. These mechanisms should be considered when designing future HiAP initiatives and their implementation to enhance the emergence of non-health sector policy-makers' engagement.

Implementation of Health 2015 public health program in Finland: a welfare state in transition.

Our study sought to examine the implementation of Health 2015 [a public health programme prepared following the principles of Health in All Policies (HiAP)] between 2001 and 2015 in the context of welfare state restructuring. We used data from the realist multiple explanatory case study by HARMONICS, which focused on political factors (processes) that lead to the (un)successful implementation of programmes following the principles of HiAP. We analyzed data-key informant interviews, grey and scholarly literature-from our Finnish case to examine how Health 2015 implementation has been affected by the changing role of the state. We find that the dismantling of formal funding allocation decreased the capacity of national authorities to exert control over municipalities' health promotion work, diluting the financial arrangements regarding municipal obligations. As a result, most municipalities failed to contribute to Health 2015, resulting in losses for health promotion activities. Our results also point to joining the EU. Whereas the procedures for preparing Finland's unanimous positions on EU matters were useful in harmonizing ideologies on various policy issues between different ministries, joining the EU also increased commercial interests and the strength of the lobby system, leading to the prioritization of economic objectives over public health objectives. Finally, our informants also highlighted the changing relationship between the state and the market, manifested in market deregulation and increasing influence of pro-growth arguments during the implementation of Health 2015.

Resisting austerity measures to social policies: multiple explanatory case studies.

Since Margaret Thatcher reached power in the United Kingdom, European governments have increasingly turned to neoliberal forms of policy-making, focusing, especially after the 2008 Great Recession on 'austerity policies' rather than investing in social protection policies. We applied a multiple explanatory case studies methodology to examine how and why challenges and resistance to these austerity measures are successful or not in four settings for three different social policy issues: using a gender lens in state budgeting in Andalusia (Spain), maintaining unemployment benefits in Italy and cuts to fuel poverty reduction programs in Northern Ireland and England. In particular, we intended to learn about whether resistance strategies are shared across disparate cases or whether there are unique activities that lead to successful resistance to austerity policies. As our approach drew from realist philosophy of science, we started with initial theories concerning collective action, political ideology and political power of affected populations. Our findings suggest that there are similarities between the cases we studied despite differences in political and policy contexts. We found that joint action between advocacy groups was effective in resisting cuts to social spending. Evidence also indicates that the social construction of target populations is important in resisting changes to social programmes. This was observed in both England and Northern Ireland where pensioners held significant political clout.

The influence of welfare state factors on nursing professionalization and nursing human resources: A time-series cross-sectional analysis, 2000-2015.

AIM: The aim of this study was to examine the relationship between welfare states and nursing professionalization indicators. DESIGN: We used a time-series, cross-sectional design. The analysis covered 16 years and 22 countries: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, South Korea, Spain, Sweden, Switzerland, United Kingdom, and the United States, allocated to five welfare state regimes: Social Democratic, Christian Democratic, Liberal, Authoritarian Conservative, and Confucian. METHODS: We used fixed-effects linear regression models and conducted Prais-Winsten regressions with panel-corrected standard errors, including a first-order autocorrelation correction. We applied the Amelia II multiple imputation strategy to replace missing observations. Data were collected from March-December 2017 and subsequently updated from August-September 2018. RESULTS: Our findings highlight positive connections between the regulated nurse and nurse graduate ratios and welfare state measures of education, health, and family policy. In addition, both outcome variables had averages that differed among welfare state regimes, the lowest being in Authoritarian Conservative regimes. CONCLUSION: Additional country-level and international comparative research is needed to further study the impact of a wide range of structural political and economic determinants of nursing professionalization. IMPACT: We examined the effects of welfare state characteristics on nursing professionalization indicators and found support for the claim that such features affect both the regulated nurse and nurse graduate ratios. These findings could be used to strengthen nursing and the nursing workforce through healthy public policies and increase the accuracy of health human resources forecasting tools.