Health Inequalities Research Research Articles

A roadmap for the nursing scientific workforce to eliminate health and healthcare inequities

Nursing science has contributed an important and unique perspective and has held a leading role in health inequity research to date. However, a number of serious workforce challenges threaten the capacity of nurse investigators to continue their leadership in solutions-oriented health inequity research. This manuscript discusses these challenges and argues that, to maintain and build on nursing’s leadership role, the nursing scientific workforce requires an improved and more modernized support infrastructure for solutions-oriented health inequities research. We also outline a series of considerations for putting such a support infrastructure in place, including overarching workforce support objectives, key workforce competencies, and important programmatic elements for a strong support infrastructure for the future cadre of solutions-oriented nurse health inequity investigators.

Associations of schooling type, qualification type and subsequent health in mid-adulthood: evidence from the 1970 British Cohort Study

BackgroundEducation is thought to benefit health. However, existing studies have predominantly focused on educational attainment—the type of institution attended has been overlooked, despite being an important indicator of education resources,...

Physical Activity in Underserved Preadolescents

Drawing insights from the theory of fundamental causes of disease, this study examined the relationships between socioeconomic status (SES) and selected risk factors in transitional urban China. Specifically, under China’s distinct institutional and sociocultural environment, we examined how contextualized SES (i.e., party membership, hukou status, housing ownership, and subjective social status) and conventional SES indicators (i.e., education, income, and occupation) were associated with physical inactivity and body mass index (BMI). Utilizing the urban subsample of the 2017 Chinese General Social Survey (CGSS), we found that individuals with higher education, income, Communist Party membership, and urban hukou status had lower risks of physical inactivity. However, higher SES with Community party membership, urban hukou, and government jobs also increased the risks of being overweight, which may be explained by potential countervailing mechanisms. These findings revealed intricate relationships among SES and risk factors in China. Our study helped contextualize the theory of fundamental causes, furnished new empirical evidence, and served as a useful reference for future health inequality research in non-Western societies.

“Power, control, strain”: Lay perceptions of health inequalities across England's ‘North South divide’

People in the North of England live shorter, less healthy lives than those in the South. Despite the significance of this ‘North South health divide’, regional health inequalities in England are under-researched qualitatively. Existing literature on geographical inequalities in health is largely confined to the neighbourhood level, is quantitative, and consists of very little lay knowledge. The current study is the first to examine lay perspectives of health inequalities on a regional level: exploring how people living in two urban areas of the North and South of England experience and perceive the North South health divide – including its causes and solutions. Using three focus group discussions with a total of 34 participants, and conducting participatory analysis, we identified three key themes: ‘inequalities of power’, ‘lack of control over lived environment’ and ‘communities under strain’. Findings align with existing research on lay perspectives of health inequalities at the neighbourhood level – identifying a network of material-structural and psychosocial factors. Participants across both regions discussed political and economic structures as central to understanding regional health inequalities, supporting calls to adopt a political economy approach in understanding health and place. Deindustrialisation, unemployment, loss of community facilities, and disengagement from politics were more present in Northern narratives than Southern. Findings add important ‘social meaning’ to emerging research on the North South health divide, reinforcing the urgency of public health professionals' recommendations for fair redistribution of power, wealth and resources to reduce regional health inequalities. In the context of government policy which diverges from public health evidence, this study sparks questions of how health inequalities research can intersect with wider social and political movements organising for systemic change.

OP8 Justice-Informed Analysis: A Unified Framework for Increasing Inclusivity and Methodological Rigor in Health Inequities Research

OP8 Justice-Informed Analysis: A Unified Framework for Increasing Inclusivity and Methodological Rigor in Health Inequities Research

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.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study

Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

How work impacts health and smoking practices among sexuality and gender minority young adults

ABSTRACT While work has been established as an important social determinant of health, it remains understudied in health inequities research. Although work has the potential to both promote and harm health, this analysis focuses on the health-compromising elements of work in a sample of sexuality and gender minority (SGM) young adults in the San Francisco Bay Area who participated in a study investigating nicotine and tobacco (NT) use practices. Survey and interview data were collected from 100 participants ages 18–25 who reported current or former NT use. In-depth qualitative interviews explored their experiences of daily life, social identities and beliefs about structural oppression, practices of NT use, and perceptions of health and wellbeing. A thematic analysis of the narratives highlighted the centrality of work to daily life. Participants described how work structured time and became a site of daily exploitation. They also identified the structural barriers that shape employment opportunities for SGM young adults, compromising health, and shaping NT use. Results elucidate the harmful practices embedded in daily work and the inequities within the structure of work itself, underscoring the need to shift focus away from individual behaviors like NT use and towards the structural factors that perpetuate health inequities.

Diversity, Equity, Inclusion, and Health Inequities Training in Neurologic Disorders and Stroke: Analysis and Recommendations From the NINDS Advisory Council Working Group.

In 2020, the National Institute of Neurological Disorders and Stroke (NINDS) leadership asked its Advisory Council to review NINDS efforts in the domains of diversity, equity, inclusion, and health inequities. Part of these efforts involved a focus on health equity training and health equity research workforce diversification activities. The objective of this article was to summarize the findings and make recommendations regarding these training activities. A subgroup of the National Advisory Neurological Disorders and Stroke Council Working Group for Health Disparities and Inequities in Neurological Disorders was engaged to advise NINDS leadership in the domain of diversity in health equity training. Activities included video teleconference meetings, multiple consultations with experienced leaders in the field, independent writing assignments, and an open public discussion as part of the NINDS HEADWAY workshop held on September 22-24, 2021. The working group recommends support for 2 distinct types of training activities: one designed for scientists from historically under-represented backgrounds and the second designed for scientists of all backgrounds performing health inequities research. Support for grant writing workshops and establishment of multi-institutional mentorship networks are recommended as potentially especially high-yield activities. The working group recommends that all NINDS-supported investigators should have sufficient diversity, equity, and inclusion training to be prepared and qualified to mentor trainees from under-represented backgrounds and mentor trainees engaged in health disparities research; there should be no "diversity tax" placed on established investigators from under-represented backgrounds to shoulder all the mentorship responsibilities. Among other recommendations, training in health disparities research should include a focus on interventional studies to alleviate inequities as well as social science and qualitative methods. There is a great deal of work to do in the field of diversity, equity, inclusion, and health inequities training, but we are optimistic that the activities outlined here, if fully implemented, will set us on the right track.

An Appreciation of a Giant in Orofacial Sciences Research—John Greenspan

Professor John S. Greenspan died on March 31, 2023. He was a renowned and accomplished academic, dentist/scientist, pathologist, and administrator who made sustained and significant international impacts on numerous fields over half a century. John was arguably best known for his work with his wife, Dr. Deborah Greenspan, on the oral aspects of AIDS and the role of viruses in oral epithelial and salivary gland lesions. He had a lifelong interest in Sjögren’s syndrome, culminating in the leadership of the Sjögren’s International Collaborative Clinical Alliance. He was also widely recognized as one of the leading investigators into the understanding of oral mucosal diseases, including recurrent aphthous stomatitis. He and his colleagues’ major contributions to HIV research and care included the discovery of the oral lesion “hairy leukoplakia,” its etiological association with Epstein–Barr virus, and other oral lesions in the natural history of HIV disease. In recent years, John turned his attention to global oral health inequalities, helping to establish the International Association for Dental Research’s Global Oral Health Inequalities Research Network and serving as its first president. He led many organizations with humble authority, knowledge, wit, and wisdom and mentored colleagues from all over the world, especially from lower- and middle-income countries. John leaves a very special legacy based on example and scientific curiosity, and his work has not only made a lasting impact on his colleagues but also translated to abiding benefit for patients.

HEALTH INEQUALITIES RESEARCH IN INDIA: A SYNTHESIS OF RECENT LITERATURE

HEALTH INEQUALITIES RESEARCH IN INDIA: A SYNTHESIS OF RECENT LITERATURE

Public Involvement & Engagement in health inequalities research on COVID-19 pandemic: a case study of CIDACS/FIOCRUZ BAHIA.

Health inequalities in Brazil have deepened on Covid-19 pandemic, and the most vulnerable people were the more affected. A multidisciplinary team from Cidacs/Fiocruz Bahia developed a Social Disparities Index for Covid-19 (IDS-COVID-19) to support the evaluation of effects of health inequalities on the pandemic in Brazil. Public Involvement and Engagement were the pillars of this research because they allowed us to access first hand experiences about the social context in our country. This paper aims to describe our Public Involvement and Engagement experience by analysing our challenges, strategies, activities, results, and lessons learned during the construction of IDS-COVID-19. The basis of the IDS-Covid-19 public engagement model was the participation of different social groups through methods and techniques that allow dialogue. Several activities and communication products supported the continuous interactions. Another guideline was the inclusion and the welcoming of participants from the beginning of the project to ensure that the participant's contributions could drive decision-making about the research. Participants made several contributions to the research as a new layer of information to the Index, and improvements were made to the interactive panel. They also compromised to support the dissemination and use of the product. Eight representatives of community groups and 29 policymakers participated in our engagement activities during the project. More than 500 people were in our open webinars. In addition, more than 140 news items about IDS-Covid-19 were published in national and international media. We highlight as lessons learned the adaptation of some dissemination formats to the public, and the necessity of being flexible and accessible to participants. We strengthened the relationship with relevant stakeholders by exploring individual conversations by phone, WhatsApp, email, and interviews to produce a documentary that registered this whole experience. Cidacs/Fiocruz Bahia has also embedded public engagement and involvement in the study agenda.

Oral health inequalities-Developments in research, policy and practice over the last 50 years.

At times of major geopolitical conflict, macroeconomic crisis and the 'aftershocks' of the COVID-19 syndemic still having a global impact, it is the most vulnerable and disadvantaged in society who undoubtedly suffer the most. During these turbulent and uncertain times, it is essential that sufficient policy attention is given to tackling the persistent and stark health inequalities that exist both between and within countries. This commentary aims to critically reflect on developments in oral health inequalities research, policy and practice over the last 50 years. Despite often challenging political contexts, progress has undoubtedly been made in our understanding of the nature and underlying social, economic and political causes of oral health inequalities. A developing body of global research has highlighted patterns of inequalities in oral health that exist across the lifecourse, but less progress has been made in implementing and evaluating policy interventions to tackle these unfair and unjust inequalities in oral health. At a global level through WHO leadership, oral health is at a 'tipping point' with a unique window of opportunity for policy change and development. Transformative policy and system reforms co-produced with community and other key stakeholders are now urgently needed to tackle oral health inequalities.

Allostatic load: historical origins, promises and costs of a recent biosocial approach

This article provides a critical and genealogical analysis of the allostatic load research framework. AL research is used as a case study to analyse how the current biosocial context is articulated in the field of health inequalities research. Providing a contemporary analysis of AL studies with a genealogy of the AL concept, we show that the ambition to use biological tools to improve measurements, predictions, and ultimately public health action, is rooted in a history that predates current biosocial entanglements. We analyse the conceptual and methodological grounding of AL studies in relation to the ambitious propositions to address health inequalities they often convey. The difficulties in translating AL research findings into public health policies and the risks of biomedicalisation that could emerge through the use of AL are also addressed. While acknowledging these risks, however, we nuance the risk of depoliticisation associated with the biomedicalisation of social inequalities in health. In light of the historical analysis, we qualify the risks associated to a biologisation of social life that could emerge from AL research: it appears that these risks are more specifically rooted in methodological and epistemological problems that researchers would need to consider in the pursuit of AL research.

Small area vulnerability, household food insecurity and child malnutrition in Medellin, Colombia: results from a repeated cross-sectional study

Malnutrition and food insecurity might be driven not only by individual factors but also by contextual conditions, such as area-level deprivation or vulnerability. This study aimed to analyze the association between area-level vulnerability and i) household food insecurity and ii) malnutrition in children in Medellin, Colombia, during the years 2017 and2018. We obtained data from two different sources: the Living Standards Measurement Survey (LSMS) and the nutrition surveillance system of Medellin. The main outcomes were food insecurity in households with children and anthropometric indicators for children under five. The main predictor was area-level vulnerability. Mixed effects Poisson regression with robust standard errors models were conducted to test the association of quintiles of deprivation with each outcome. Households with children living in areas with the highest deprivation had 1.9 times the prevalence of food insecurity as compared to those living in areas with the lowest deprivation (PR 1.91, 95% CI 1.42-2.57). Similar results were observed for underweight/risk of underweight (PR 1.26, 95% CI 1.11-1.42), stunting/risk of stunting (PR 1.36, 95% CI 1.22-1.53) and stunting (PR 1.93 95% CI 1.55-2.39) among children under five. We found no consistent associations with wasting/risk of wasting or excess weight/risk of overweight across quintiles of deprivation. This study sheds light on the role of area-level vulnerability on malnutrition in children in Medellin, Colombia, showing a pattern of increasing prevalence of food insecurity, underweight and stunting by quintile of deprivation. Swiss School of Public Health (SSPH+) and Centre for Global Health Inequalities Research (CHAIN).

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

BackgroundEvidence 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.MethodsWe 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.ResultsWe 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.ConclusionsValuable 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.

Assessing the risk of endogeneity bias in health and mortality inequalities research using composite measures of multiple deprivation which include health-related indicators: A case study using the Scottish Index of Multiple Deprivation and population health and mortality data.

The inclusion of health-related indicators in composite measures of multiple deprivation introduces a risk of endogeneity bias when using the latter in health inequalities research. This bias may ultimately result in the inappropriate allocation of healthcare resources and maintenance of preventable health inequalities. Mitigation strategies to avoid this bias include removing the health-related indicators or using single constituent domains (such as income or employment class) in isolation. These strategies have not been widely validated. This study used population-level health and mortality data with a contemporary composite measure of multiple deprivation (Scottish Index of Multiple Deprivation; SIMD) to assess these mitigation strategies. The differences between deprivation methods (original, health excluded, and income domain) were negligible. The results of quantitative research on health inequalities are unlikely to be affected by endogeneity bias.

Neighbourhood-related socioeconomic perinatal health inequalities: An illustration of the mediational g-formula and considerations for the big data context.

Advances in computing power have enabled the collection, linkage and processing of big data. Big data in conjunction with robust causal inference methods can be used to answer research questions regarding the mechanisms underlying an exposure-outcome relationship. The g-formula is a flexible approach to perform causal mediation analysis that is suited for the big data context. Although this approach has many advantages, it is underused in perinatal epidemiology and didactic explanation for its implementation is still limited. The aim of this was to provide a didactic application of the mediational g-formula by means of perinatal health inequalities research. The analytical procedure of the mediational g-formula is illustrated by investigating whether the relationship between neighbourhood socioeconomic status (SES) and small for gestational age (SGA) is mediated by neighbourhood social environment. Data on singleton births that occurred in the Netherlands between 2010 and 2017 (n=1,217,626) were obtained from the Netherlands Perinatal Registry and linked to sociodemographic national registry data and neighbourhood-level data. The g-formula settings corresponded to a hypothetical improvement in neighbourhood SES from disadvantaged to non-disadvantaged. At the population level, a hypothetical improvement in neighbourhood SES resulted in a 6.3% (95% confidence interval [CI] 5.2, 7.5) relative reduction in the proportion of SGA, that is the total effect. The total effect was decomposed into the natural direct effect (5.6%, 95% CI 5.1, 6.1) and the natural indirect effect (0.7%, 95% CI 0.6, 0.9). In terms of the magnitude of mediation, it was observed the natural indirect effect accounted for 11.4% (95% CI 9.2, 13.6) of the total effect of neighbourhood SES on SGA. The mediational g-formula is a flexible approach to perform causal mediation analysis that is suited for big data contexts in perinatal health research. Its application can contribute to providing valuable insights for the development of policy and public health interventions.

Clarifying how social epidemiological research constructs the category of low socioeconomic status: A response to Kamphuis et al.

In our previous article, published in this journal, we argued that epidemiology has a constructive role with regard to socioeconomic health inequalities. We concluded that, as long as the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations ‘known to be unhealthy’. Recently, in this journal, Kamphuis et al. responded to our article. While they welcomed our reflections, the authors also posed critique to our arguments. In this paper, we respond to that critique and deepen the discussion on the use of (L)SES categories in social epidemiology. For this purpose, we further clarify our arguments and state that in health inequality research it is important to: 1) Pay attention to the unintended effects of research; 2) Consider the origin and effects of explanatory concepts; and 3) reflect on the norms of cultural capital.

Participatory and deliberative processes in the UK related to income insecurity: a scoping review

BackgroundDemocratising decision making related to socioeconomic policy is an area of growing interest in health inequalities research; however, there is a recognised gap between the democratic theory and practical application at a macro socioeconomic level. This gap is notable in the current UK policy context defined by over a decade of austerity, rising income insecurity, and an increase in health inequalities. Underpinned by theories related to participatory, deliberative, and economic democracy, particularly those concerned with democratic innovations, this scoping Review investigates how, when, and where participatory and deliberative processes have been used to influence socioeconomic policy over the past 15 years in the UK and how this influence might inform any so-called democratic rejuvenation moving forward. MethodsThis Review, presenting the interim findings, is structured in accordance with the Joanna Briggs Institute's guidance for conducting systematic scoping reviews and applies the PRIMSA-Scoping Review checklist. Key search terms included “public policy”, “economic policy”, “income insecurity”, “poverty”, “public participation” “decision-making”, and “democratic innovation”. Searches were conducted in EconLit, SOC Index, Sociological Abstracts, and MedLine, as well as grey literature sources, including BASE database, government, third sector, and thinktank websites for articles related to participatory and deliberative processes (informed by theories of associative and direct democracy as well as Fung's Democracy Cube of public participation) in socioeconomic policy making in the UK, in English, from January, 2007, until June, 2022. A combined framework of democratic goods and typology of interventions to tackle health inequalities were applied for analysis. Findings14 articles were included in the final review (three peer-reviewed and 11 grey literature) with a concentration of results in Scotland (six articles) and in local government (five articles). Interim findings suggest a multiplicity of activities exist under the banner of participatory and deliberative processes; however, there are few, if any, examples that influence typically closed macro socioeconomic policy making and instead disperse participatory decision-making across less empowered spaces. InterpretationAmbitions for a democratic rejuvenation to tackle the upstream socioeconomic drivers of health inequalities require critical reflection on the locus of decision-making power, as well as the fractured and challenging nature of participatory policy making. FundingThis study is part of a PhD studentship with the Medical Research Council and Chief Scientist Office, Social and Public Health Sciences Research Unit at the University of Glasgow. The studentship is funded by the Medical Research Council (MC_UU_00022/3) and Chief Scientist Office of the Scottish Government Health Directorates (SPHSU18). KS is funded by the Medical Research Council (MC_UU_12017/11 and MC_UU_00022/3) and Strategic Award (MC_PC_13027) and Chief Scientist Office of the Scottish Government Health Directorates (SPHSU18). GF is funded through the UK Medical Research Council (MC_ UU_00022/2) and the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU17).