Health and health behaviours before and during the Great Recession, overall and by socioeconomic status, using data from four repeated cross-sectional health surveys in Spain (2001-2012).

BackgroundInterest in applying a complex systems approach to understanding socioeconomic inequalities in health is growing, but an overview of existing research on this topic is lacking. In this systematic scoping review, we summarize the current state of the literature, identify shared drivers of multiple health and health behavior outcomes, and highlight areas ripe for future research.MethodsSCOPUS, Web of Science, and PubMed databases were searched in April 2023 for peer-reviewed, English-language studies in high-income OECD countries containing a conceptual systems model or simulation model of socioeconomic inequalities in health or health behavior in the adult general population. Two independent reviewers screened abstracts and full texts. Data on study aim, type of model, all model elements, and all relationships were extracted. Model elements were categorized based on the Commission on Social Determinants of Health framework, and relationships between grouped elements were visualized in a summary conceptual systems map.ResultsA total of 42 publications were included; 18 only contained a simulation model, 20 only contained a conceptual model, and 4 contained both types of models. General health outcomes (e.g., health status, well-being) were modeled more often than specific outcomes like obesity. Dietary behavior and physical activity were by far the most commonly modeled health behaviors. Intermediary determinants of health (e.g., material circumstances, social cohesion) were included in nearly all models, whereas structural determinants (e.g., policies, societal values) were included in about a third of models. Using the summary conceptual systems map, we identified 15 shared drivers of socioeconomic inequalities in multiple health and health behavior outcomes.ConclusionsThe interconnectedness of socioeconomic position, multiple health and health behavior outcomes, and determinants of socioeconomic inequalities in health is clear from this review. Factors central to the complex system as it is currently understood in the literature (e.g., financial strain) may be both efficient and effective policy levers, and factors less well represented in the literature (e.g., sleep, structural determinants) may warrant more research. Our systematic, comprehensive synthesis of the literature may serve as a basis for, among other things, a complex systems framework for socioeconomic inequalities in health.

BackgroundMaterial, psychosocial and behavioural factors are important explanatory pathways for socioeconomic inequalities in health. The aim of this systematic review was to summarise the available evidence on empirical studies and...

The recent economic recession, documented to have lasted from December 2007 to June 2009 and labeled as the "Great Recession," has affected prospects for financial security and health among populations of many countries. Recent research about the health impacts of the Great Recession has predominantly focused on adults. This chapter explores the extent to which the Great Recession relates to changes in health and socioeconomic health inequalities in adolescents (aged 11 to 15 years) in Europe, North America, and Israel. Using data from the Health Behaviour in School-aged Children (HBSC) study that were collected before the onset of the recent recession (in 2005/2006) and a few years after it began (in 2009/2010), we found that changes in both national prevalence rates and socioeconomic inequalities in psychological health complaints were mostly modest during the Great Recession. Moreover, the effects of the Great Recession, indicated by change rates in youth and adult unemployment between 2005/2006 and 2009/2010, did not significantly correlate to psychological health complaints and socioeconomic inequalities in psychological health complaints. From a cross-national perspective, health and socioeconomic health inequalities in adolescence appear to have been unaffected by the Great Recession.

Socioeconomic Inequalities in Adolescent Health

Background and AimHealth is viewed as a form of human capital and a necessary basis for people to realize capabilities. Moreover, socioeconomic inequality in health outcome widens income inequality and exacerbates social inequality. The aim of this study is to measure socioeconomic inequality in health outcomes among the elderly in China.MethodsThe data used in this study were sourced from China Health and Retirement Longitudinal Study in 2015, including 5643 participants aged 60 and above. Concentration curve and concentration index were applied to measure the extent of socioeconomic inequality in health outcomes among older adults. Furthermore, the decomposition method of concentration index proposed by Wagstaff was employed to quantify each determinant’s contribution to the measured socioeconomic inequality in health outcomes.ResultsThe concentration index of Activity of Daily Living Scale and Center of Epidemiological Survey-Depression Scale score were −0.0064 and −0.0158, respectively, indicating pro-rich inequality in physical and mental health among the elderly. The decomposition analysis revealed that household income (41.15%), aged 70–79 (17.37%), being male (8.38%), and living in urban area (5.78%) were key factors to explain the pro-rich inequality in physical health. Furthermore, the results also suggested that household income (68.41%), being male (17.55%), having junior high school education (10.67%), and living in urban area (6.49%) were key factors to explain the pro-rich inequality in mental health.ConclusionThis study revealed that there are pro-rich inequalities in physical and mental health among the elderly in China, and the degree of pro-rich inequality in mental health is higher than that in physical health. Moreover, the results also suggested that household income is the biggest contributor to socioeconomic inequality in physical and mental health. Furthermore, this study found that educational attainment makes a substantial contribution to socioeconomic inequality in health outcomes, while the contribution of health insurance to health inequality is limited.

Researching health inequalities in adolescents: The development of the Health Behaviour in School-Aged Children (HBSC) Family Affluence Scale

An evolution of socioeconomic inequalities in self-rated health in Korea: Evidence from Korea National Health and Nutrition Examination Survey (KNHANES) 1998–2018

Socio-economic inequalities in health may change over time, and monitoring such change is relevant to inform adequate policy responses. We aimed to quantify socio-economic inequalities in health among people with direct, indirect and without migration background in Germany and to assess temporal trends and changes between 1995 and 2017. Using nationally representative survey data from the Socio-Economic Panel (SOEP), we quantified absolute and relative socio-economic inequalities in self-reported general health by calculating the slope (SII) and relative index of inequality (RII) with 95% confidence intervals (CI) among each group and year (1995–2017) in a repeated cross-sectional design. Temporal trends were assessed using a GLM regression over the SII and RII, respectively. The total sample size comprised 492,489 observations, including 108,842 (22.23%) among people with migration background. About 31% of the population with and 15% of the population without migration background had a low socio-economic status. Socio-economic inequalities in health persisted in the group with migration background (1995 to 2017), while inequalities in the non-migrant population increased (SII: = 0.04, p < 0.01) and were on a higher level. The highest socio-economic inequalities in health were found among those with direct migration background ( = −0.23, p< 0.01; = −0.33, p < 0.01). The results show that the magnitude and temporal dynamics of inequalities differ among populations with direct, indirect and without migration background. Monitoring systems can capture and investigate these inequalities if migrant populations are adequately integrated into the respective systems.

Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study

The rapid growth in life expectancy of four years over the past two decades in most EU countries is a great testament to the success of achieving healthy ageing (1). In any ageing society, it is of paramount importance for economic prosperity to prolong working life in order to balance a population of active versus inactive persons. However, health and wealth are not distributed very fairly across society. Poorer educational attainment and lack of paid employment are persistent causes for inequalities in health and wealth (2). There is ample evidence of a recent widening of social inequalities in life expectancy in many countries. In Denmark – one of the most egalitarian societies in the world – educational inequality life expectancy increased among men from 4.8 years in 1987 to 6.4 years in 2011. For women, an increase was observed from 3.7 to 4.7 years (3). Two important theories are put forward to explain this striking development. The first theory points at the strong trend of decreasing prevalence of unhealthy behaviors with higher educational attainment. Since health promotion programs generally have higher uptake and effectiveness among better educated persons (4), the so-called “intervention-generated inequalities” might contribute to increased inequalities (3). The second theory posits that labor market conditions are more unfavorable for those with lower education and their jobs are more strenuous as well (3). A recent comparative study across selected European countries showed that lower educated persons had substantially higher rates of disability and unemployment and also had more often less stable employment contracts (5). A longitudinal study among older workers in 11 European countries reported that among work-related factors studied, perceived lack of job control was consistently a risk factor for disability benefits, unemployment, and early retirement during the four years of follow-up (6). Many countries are developing policies and strategies to encourage workers to remain at work longer. These seldom take into account the particular role of health and working conditions, which impact the ability of older workers to remain in paid employment until statutory retirement age. For example, if strenuous work has adverse effects on health, especially at older age with declining physical and cognitive functions, timely retirement may be health-preserving. It may also prevent such workers from spending the required added years before retirement in disability and unemployment rather than paid employment. The current issue of the Scandinavian Journal of Work, Environment & Health contains publications that contribute to the unravelling the role of work in socioeconomic inequalities. Addressed in this issue, two distinct mechanisms can be distinguished: educational differences in working conditions encountered on the job and educational attainment as a determinant of labor market position. The first study by Kaikkonen and colleagues (7) demonstrates a marked socioeconomic gradient in sickness absence in a longitudinal study with 8-year follow-up among Finnish citizens. The difference between the lowest and highest educational level was 4.8 days/year (60%) among men and 5.7 days/year (56%) among women for registered episodes of sickness absence of ≥10 days. In a mediation analysis, about 20–25% of these differences could be attributed to self-reported health status, health behavior, and physical and psychosocial working conditions. Interestingly, the crude influence of physical working conditions was substantially higher than all other factors with a maximum effect of 1.2–1.4 days/year (7). The study has several limitations that hamper more precise estimates of the direct and indirect effects of working conditions, health, and health behavior. For example, these factors were all based on self-reports in the baseline questionnaire and, thus, may suffer from common source bias. Another obvious problem is that these factors were measured only at baseline and treated as time-independent variables in the statistical analysis. When working conditions, health, and health behavior vary considerably over time, the reported associations will most likely underestimate the impact of these factors on sickness absence. A third point of concern may be that only sickness absence periods of ≥10 days were available from the register, but other studies have indicated that educational differences are more prominent in longer sickness absence periods (8). In spite of this critique, the study certainly corroborates the hypothesis that educational differences in working conditions have a substantial impact on the ability of workers to be productive at work. It complements earlier studies on educational differences in disability benefits due to musculoskeletal disorders linked to physically demanding work (9), and physical strain and low job control as explanatory factors for educational differences in disability benefits (10). The second publication presents a longitudinal study with 6-year follow-up among a national sample of households in Korea. Using annual waves with time-varying information on independent and dependent variables, precarious employment was associated with onset of severe depressive symptoms with a stronger effect among women than men. Moreover, change from a permanent to a temporary employment contract was also associated with an increase in onset of severe depressive symptoms. Precarious employment was more prevalent among those with intermediate or lower education, hence, employment status at the labor market introduced social inequalities (11). These results reflect previous reports in Asia that precarious employment increased the risk on serious psychological distress (12) and in Finland where adverse effects were observed for prolonged sickness absence and disability pension for depression, especially among the lower educated and older workers (13). Given the rapid growth in flexible labor contracts in most countries, their impact on socioeconomic health inequalities raises concerns on the effectiveness of current policies and social and institutional systems for temporary employees that will support them to work longer in good health. There is increasing evidence that work plays a key role in socioeconomic health inequalities. However, there is a shocking lack of evidence how current labor market and retirement policies will influence socio-economic inequalities in health and wealth. Currently available evidence suggests that disparities may increase when these policies are blind to the mechanisms of how work influences health. There is an urgent need for studies that present empirical evidence on the consequences of the rapid changes in national policies on disability and retirement aimed at prolonging working careers for the health of the workforce.

Health inequalities in Israel: Explanatory factors of socio-economic inequalities in self-rated health and limiting longstanding illness

Aims: The so-called 'Great Recession' in Europe triggered widespread concerns about population health, as reflected by an upsurge in empirical research on the health impacts of the economic crisis. A growing body of empirical studies has also been devoted to socioeconomic inequalities in health during the Great Recession. The aim of the current study is to summarise this health inequality literature by means of a scoping review. Methods: We have performed a scoping review of the research literature (English language) published in the years 2012-2017. Only empirical papers with (a) health status measured on the individual level, (b) information on socioeconomic position (i.e. employment status, educational level, income/wealth, and/or occupational class), and (c) data from European countries in both pre- and post-crisis years were considered relevant. In total, 49 empirical studies fulfilled these inclusion criteria. Results: The empirical findings in the 49 included studies predominantly show that socioeconomic inequalities in health either increased or remained stable from pre- to post-crisis years. Two-thirds (65%) of the studies found evidence of either increasing or partially increasing health inequalities. Thus, people in lower socioeconomic strata fared worse overall in terms of health during the Great Recession, compared to people with higher socioeconomic status. Conclusions: The Great Recession in Europe tends to be followed by increasing socioeconomic inequalities in health. Policymakers should take note of this finding. Widening socioeconomic inequalities in health is a major cause of concern, in particular if health deterioration among 'vulnerable groups' is caused by accelerating cumulative disadvantages.

ObjectivesTo examine trends in socioeconomic inequality in adolescent health over three decades, across fifteen health indicators: overweight, underweight, headache, stomachache, backpain, emotional symptoms, difficulties falling asleep, loneliness, low life satisfaction, low self-rated heath, smoking, drunkenness, physical inactivity, low vegetable intake, and inadequate toothbrushing.MethodsThe Health Behaviour in School-aged Children (HBSC) study in Denmark included nine identical surveys of 11–15-year-olds from 1991 to 2022, n = 35,423. For each health indicator, we measured absolute and relative socioeconomic inequality by prevalence differences and odds ratios between low and high socioeconomic groups.ResultsThere was socioeconomic inequality in thirteen health indicators, e.g., the OR (95% CI) for overweight in low vs. high socioeconomic groups was 2.22 (1.95–2.49). This social inequality persisted across health indicators throughout the study period with two deviations: Underweight was not associated with socioeconomic background and drunkenness was persistently most prevalent in higher socioeconomic groups.ConclusionThe political efforts to reduce socioeconomic inequality in health seems to have failed. It is important to improve monitoring of adolescent health and implement improved policies to tackle socioeconomic inequality in adolescent health.

SINCE THE LATE 1970S AND EARLY 1980S, A FUNDAmental question surrounding the relationship between socioeconomic factors and health status has been: How much of socioeconomic differences and health can be attributed to socioeconomic differences in health behaviors? The article by Stringhini and colleagues in this issue of JAMA represents an important contribution to understanding the social determinants of health by providing a better answer than previously available about this fundamental issue. This question is important because even though the patterning of a wide variety of health outcomes by socioeconomic status has been demonstrated in numerous studies, well-established behavioral health risk factors, such as smoking, physical activity, dietary patterns, and alcohol consumption, also show a similar socioeconomic gradient. For the most part, after controlling for relevant health behaviors, there is still a significant amount of variation in health outcomes to be explained by socioeconomic factors. Moreover, socioeconomic inequalities in health are not reducible to health behaviors, although these inequalities are part of what creates them. Based on repeated measurement of health behaviors in the Whitehall cohort of British civil servants, Stringhini et al show that health behaviors explain a great deal more of class inequalities in mortality than observed in previous studies. Many who will dispute the study’s findings have moved on from this debate long ago, having been satisfied that the investigation of the association of socioeconomic factors with health was an important area of inquiry even after taking into account behavioral factors. Efforts to dismiss socioeconomic inequalities in health as mere reflections of socioeconomic differences in health behaviors have been criticized as a politically safe interpretation that reinforces a status quo of significant and increasing social, economic, and health injustice within and between nations. Some proponents of health behavioral explanations for inequalities in health most likely will agree with the findings of this report. However, this study is important for the new issues it raises, some of which transcend this debate. Perhaps most important, the study by Stringhini et al does not suggest that socioeconomic differences in health are reducible to socioeconomic differences in unhealthy behaviors. Accordingly, it would be incorrect to infer that there is no need to be concerned with social and economic justice, only health behavior. There are several reasons for this important caveat, which raise other questions. First, the study by Stringhini et al is based on a relatively unique group of British adults, possibly becoming more unique as time passes. The Whitehall study has been conceptualized by some as a relatively narrow band of the overall socioeconomic spectrum in British society, and the repeated finding that lower-ranked civil servants experienced poorer health on a wide variety of outcomes was thought to indicate that it was possible to simply extrapolate the pattern at both ends of the gradient to individuals with lower or higher socioeconomic status outside of the civil service. By this logic, findings from the Whitehall cohort would be considered a reflection of British society at large. However, scientists involved in the Whitehall study have not encouraged this interpretation and have been careful to indicate that participants in the Whitehall cohort may be quite distinct. Second, the debate surrounding factors accounting for health status has been characterized as a simplistic matter of the stress of low socioeconomic status vs behavior as the explanation for socioeconomic inequalities in health. With a broader conceptualization of stress, it is possible to consider both factors as part of the same pathway between relatively low socioeconomic status and health. Unhealthy behaviors are more common among individuals with low socioeconomic status because of the stress of low socioeconomic status. Accordingly, there is a direct causal pathway between low socioeconomic status and poor health as well as an indirect causal pathway through health behavior, which reinforce one another over the lifecourse. That is, the stress pathway is partly a behavioral pathway and unhealthy behaviors are coping mechanisms for the stress of low socioeconomic status. This observation does not dis-

BackgroundA complex systems perspective is gaining popularity in research on socioeconomic inequalities in health and health behaviour, though there may be a gap between its popularity and the way it is implemented. Building on our recent systematic scoping review, we aim to analyse the application of and reporting on complex systems methods in the literature on socioeconomic inequalities in health and health behaviour.MethodsSelected methods and results from the review are presented as a basis for in-depth critical reflection. A traffic light-based instrument was used to assess the extent to which eight key concepts of a complex systems perspective (e.g. feedback loops) were applied. Study characteristics related to the applied value of the models were also extracted, including the model evidence base, the depiction of the model structure, and which characteristics of model relationships (e.g. polarity) were reported on.ResultsStudies that applied more key concepts of a complex systems perspective were also more likely to report the direction and polarity of relationships. The system paradigm, its deepest held beliefs, is seldom identified but may be key to recognize when designing interventions. A clear, complete depiction of the full model structure is also needed to convey the functioning of a complex system. We recommend that authors include these characteristics and level of detail in their reporting.ConclusionsAbove all, we call for the development of reporting guidelines to increase the transparency and applied value of complex systems models on socioeconomic inequalities in health, health behaviour and beyond.Graphical