Health Inequalities Research Articles

4.Y.2. Building inclusive risk communication, community engagement and infodemic management strategies

Abstract Public health crises have their most devastating effects on people who are marginalized due to structural vulnerability mechanisms. As a reflection of this phenomenon, the Novel Coronavirus Disease (COVID-19) pandemic as a public health crises has increased the vulnerability of groups such as refugees, asylum-seekers and LGBTQ+ individuals facing discrimination, stigmatisation, displacement, economic instability, risk environments, precarious living and working conditions among others, and health inequities have been further deepened. A critical post-pandemic task is to develop comprehensive crisis response plans that prioritize inclusivity and address diverse needs. Integral to these plans are Risk Communication (RC), Community Engagement (CE), and Infodemic Management (IM) strategies. While international organizations have provided guidelines for RCCE-IM, there is an urgent need to translate these principles into tailored, context-specific strategies that account for the unique circumstances and requirements of diverse groups. The aim of this workshop is to reflect the lessons learned from the COVID-19 pandemic to strengthen the RCCE-IM strategies, using the cases of migrants and LGBTQ+ people, two groups who are intensively influenced by structural vulnerability mechanisms. The first 20 minutes of this workshop will feature four short presentations. First, the concepts of RCCE-IM will be defined, followed by an explanation of why related strategies should differ for vulnerable groups. The second presentation will focus on the issues that LGBTQ+ people faced during the COVID-19 pandemic, as well as their specific RCCE-IM needs. The third and fourth presentations are based on a collective project taking an expert perspective on the RCCE experience with migrants during the COVID-19 pandemic. Firstly, the extent to which the RCCE actions in Munich, Germany, has been able to include asylum-seekers and areas for improvement will be presented. This will be followed by a presentation on recommendations to enhance RCCE of the experts who were working with undocumented migrants, unaccompanied minors, and newly arrived refugees in Malmö, Sweden. In the final part of the workshop, participants will be invited to provide brief recommendations on the operationalization of international RCCE-IM principles across four key thematic areas: 1) Rapid adaptation of RC materials to culture and context, 2) Trust-building in crisis, 3) Navigating sociocultural and linguistic diversity, 4) Addressing LGBTQ+ migrants in RCCE activities. Key messages • Addressing vulnerable groups in (public) health and humanitarian crises using RCCE-IM strategies are needed to leave no one behind. • To conduct inclusive RCCE-IM activities, cities need to address structural vulnerabilities, identify different needs and context-based strategies, and integrate various sectors and perspectives.

Comparison of perinatal hospital services of women living in Roma settlements in Slovenia

Abstract Background Women living in Roma settlements in Slovenia had worse perinatal health indicators comparing with women from the rest of population. They gave more births in younger age and used fewer preventive services and later in pregnancy. Roma children had higher chances to be born earlier and with lower birth weight. We explored the differences in provided hospital services between pregnant Roma and the rest of female population in Slovenia. Methods We identified the female inhabitants of Roma settlements from the national registry of population and separated from the rest of the population data. Health indicators were provided from the national health register - Perinatal Information System for the years from 2018 to 2022. The frequency statistics, ANOVA and comparison of column proportion tests were used (p-value<0.005, 95% CI) to compare the differences in categories of services in those two groups. Results Statistically significant differences were found in several hospital services comparing treatments of pregnant females from Roma settlements comparing to the rest of female population. Women from Roma settlements had higher ratio of gynecologic history without remarks, fewer treatments and less prevention investigations in prenatal period and higher ratio of natural start of delivery. In addition, by Roma females was used less medication during delivery, less episiotomies and fewer caesarean section were performed. Conclusions There are significant differences in provision of hospital services between female inhabitants of Roma settlements and the rest of population. Some of them could be explained by younger average age of delivery in Roma, but additional research would bring more light in possible impact of socio-economic and cultural determinants on both the use and provision of health services. Key messages • There are differences in provided health services between Roma women and the rest of female population. In depth research of prenatal and hospital services would bring additional explanations. • Considering the health inequalities which start by birth, targeted and tailored actions to improve health of Roma women and their new-borns are appropriate and necessary.

“I stayed on the street, as if there was no COVID-19”: enacting practices of care with youth at risk of violence and social exclusion in Portugal

As the COVID-19 pandemic unfolded, a world of carelessness was made visible. Public health guidelines against the spread of COVID-19 (e.g., school closures, staying home, social distancing) have substantially affected youth’s health and well-being and highlighted the need for context-specific understandings of infection, risk, and care. Our research aims to contribute to a deeper understanding of the impacts of COVID-19 on boys and girls serving educational measures and placed in the custody of the juvenile justice system in Portugal during the pandemic. Sustained by the use of ethnographic principles and methods along with participatory techniques, this article uncovers complex entanglements between the public health measures to mitigate contagion and the dynamics that exacerbated socio-spatial dynamics of social exclusion and isolation, educational and (mental) health inequities, and lived and practiced forms of violence by youth-serving tutelary measures in Portugal’s six educational centers. Following Tronto’s feminist ethical–political proposal of care, I argue that COVID-19 became a lens to access youth care needs — self-care, care for others, care as essential work of nurturing affective trajectories and solidarities and promoting positive and non-violent relationships. By caring for youth stories, the engagement of researchers and professionals in this action-oriented research aimed to promote the enactment of practices of care with youth in the Portuguese detention centers as a way to positively affect their inhabited present, promote healthier lives and nurture the construction of caring and non-violent post-pandemic futures.

Active education for reducing the attainment gap in a public health course in the United Kingdom (UK)

Abstract Background A diverse cohort of students join our UK postgraduate public health programme. We wanted to reduce attainment gaps between students. Active and inclusive educational activities may be important mechanisms for reducing attainment gaps as well as promoting student wellbeing. Our aim was to explore how active and inclusive curriculum design could support development of public health functions (e.g., designing interventions to address health inequalities) whilst reducing attainment gaps. Objectives Our 12-week module included a project to model determinants of adolescent’s health inequalities and design an evidence-based intervention to address determinants. Informed by Fink’s taxonomy and the assessment for learning framework, we designed educational activities (i.e., small group work and presentations, ethnographic visits, discussions with stakeholders) and assessments (i.e., group poster presentation and individual critical reflection) to structure the project. We assessed attainment gaps in student marks and surveyed student attitudes to the project (1 = strongly disagree; 5 = strongly agree). Results 53 students (9 groups) completed the assessment with the following marks: poster (M = 61, SD = 7), critical reflection (M = 59, SD = 9), overall mark (M = 59, SD = 10). More students received ‘fails’ and ‘distinctions’ when only the critical reflection was considered (p < 0.001). Students (N = 39; 72% response rate) agreed that activities were intellectually stimulating (M = 5, SD = 0.8), supported their learning (M = 4, SD = 0.8) and made them feel included (M = 5, SD = 0.7). Active learning approach (i.e., benefits of interactions; creating effective groups); student’s caring and commitment; choice and inclusivity; complex and authentic tasks; informal, formal and timely feedback were highlighted. Conclusions Evidence that an active and inclusive approach functions to reduce attainment gaps is equivocal but appears to promote engagement, inclusion and learning. Key messages • Active learning strategies combined with authentic and flexible tasks and rich in feedback stimulate student’s interactions, inclusivity, and learning with potential for reducing attainment gaps. • Active and authentic education requires educators to work on how to properly implement these strategies.

Quantifiable Cross-cultural Research on Medical Mistrust is Necessary for Effective and Equitable Vaccination in Low- and Middle-income Countries.

Perceptions of healthcare personnel and institutions substantially impact healthcare behaviors. In the US, minority experiences with racist events like the Tuskegee study, alongside everyday experiences of marginalization and discrimination, drive medical mistrust in populations that are already burdened with health inequalities. However, the concept of medical mistrust is rarely applied outside of industrialized contexts. Histories of colonialism, underfunded healthcare institutions, and the enormous cultural and ethnolinguistic diversity present in low- and middle-income countries (LMICs) make medical mistrust a likely contributor to health behavior in these contexts. In the era of COVID-19 and emergent malaria vaccines, there is an urgent need to mitigate factors leading to medical mistrust, which impedes interest in novel vaccines. Doing so requires substantial investment in research that examines the causes of medical mistrust across diverse communities, develops methodological tools that can effectively measure medical mistrust across diverse cultural and ethno-linguistic contexts, and applies this data to policy and public health messaging. This commentary highlights the role of medical mistrust in vaccination and argues for its utility in addressing vaccine decision-making in LMICs.

The effect of health literacy course on the level of health literacy in medical students

Abstract Health literacy (HL) concerns not only individuals but also health systems and health professionals. Most of the literature on HL has focused on patient factors, with little emphasis on the communication skills and practices of health professionals. Training is needed at all levels to understand the concept of HL and its impact on health inequalities. This study is an intervention study. Data were collected from 29 students taking the third year elective course at the Faculty of Medicine through an online survey. The survey consists of 40 questions aimed at assessing the demographic characteristics of the participants, the TSOY-32 Scale and some factors affecting HL. During the training period, role-play scenarios were played to teach the importance of HL, sample videos were watched to evaluate physician-patient communication, and case studies were conducted. The mean pre-test TSOY-32 scale score of the participants was 32.8±5.8. The mean post-test TSOY-32 scale score was 36.4±7.1. There was a significant difference between pretest and posttest groups in terms of TSOY-32 scale score (p = 0.033). Health professionals often overestimate patients’ HL levels and do not have sufficient competence to effectively manage limited HL. These gaps need to be addressed through the curricula of medical schools and specialties. Key messages • Training on health literacy improves medical students’ communication skills, bridging gaps in patient care. • Addressing health literacy in medical training enhances patient-doctor communication, vital for quality care.

Reporting social inequalities in health dashboards: data source mapping of 14 European countries

Abstract Background Monitoring health inequalities is an essential public health task. This includes reporting social inequalities using data dashboards to inform citizens and policy-makers. To date, there is a dearth of evidence on the extent of health inequality reporting and which equity dimensions are being reported in European countries. The aim of the study is to systematically map data sources and identify the equity dimensions reported in national and subnational data sources in 14 European countries. Methods Study design is a cross-sectional data source mapping in 14 European countries (Bulgaria, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Iceland, Malta, Norway, Portugal, Slovenia, Spain). We will conduct a survey among more than 400 collaborators of the EU-funded Joint Action to Prevent NCDs (JAPreventNCD) to identify existing population health dashboards at national and subnational levels. On a second stage, we will carry out a structured content audit to identify inequality dimensions and health indicators in each dashboard. The dashboard content audit will be done in duplicate by native speakers using keyword search and annotated navigation. Inequality dimensions will be categorised using PROGRESS-plus categories. We will pre-register the protocol in OSF prior to data collection and analysis. Data analysis will use a modified version of the template developed by the World Health Organization. Data analyses will be conducted in R. Work is under development but given the resources committed to JAPreventNCD, results will be ready by November 2024. Key messages • Reporting social inequalities using data dashboards to inform citizens and policy-makers is an essential public health task. • Systematic data source mapping can be a reliable, efficient method to monitor the routine reporting of health inequalities.

Educational inequalities in cervical cancer mortality: A systematic review and meta-analysis

Abstract Background Educational inequalities in mortality continue to persist. We aimed to systematically analyse the association between level of education and cervical cancer mortality. Methods We conducted a systematic review and meta-analysis. We systematically searched Pub-Med, Web of Science, Scopus, EMBASE and Global Health (CAB), EconLit and Sociology Source Ultimate databases. A protocol has been registered with PROSPERO (CRD42023411757). We included studies that measured the association between level of education and cervical cancer mortality using individual level data. Included articles were assessed for study quality and risk of bias using the Joanna Briggs Institute critical appraisal checklists. A random-effects meta-analysis was conducted to evaluate the overall and stratified effects of education on mortality. Findings Our literature search resulted in over 47,000 articles. 30 studies mentioned cervical cancer as a cause of death, and of these, 11 were eligible for the meta-analysis. Results showed an overall risk ratio of 2.41 (95% CI 1.81-3.20) for low education (ISCED 0-2) and 1.62 (95% CI 1.18-2.24) for medium education (ISCED 3-4). Those aged 25-64 with low education had more than twice the risk of cervical cancer (RR = 5.73; 95% CI 5.04-6.51) compared to those aged 25 and above (RR = 2.11; 95% CI 1.82-2.45). Besides, the impact of an additional level of education on reducing risk of cervical cancer mortality was higher in Northern Europe, compared to the South. Interpretation Lower educational attainment is associated with an increase in the risk of cervical cancer mortality, with an additional level of education greatly reducing this risk in Northern Europe. Younger cohorts with low education have a higher risk of cervical cancer mortality. This study provides important information for evidence-based policy seeking to reduce health inequities and inequalities in both the health and education sector. Key messages • Lower educational attainment is linked to a higher risk of cervical cancer mortality. • Younger cohorts (aged 25-64) with low education are at a particularly heightened risk compared to those aged 25 and above.

Adapting, expanding and embedding community and culture into health ecosystems

Abstract Background Community anchor organisations (CAOs) work with communities who experience health inequalities and disadvantage, providing a range of activities and services to meet individuals’ needs in an integrated way. This study explored how CAOs use art, cultural and nature-based activities as part of their work to respond to the needs of people facing inequalities and considered how activities can be scaled in this health setting. Methods This study used community-based participatory research within a case study approach to work with four purposively sampled CAOs. Participants were community members, volunteers, staff, trustees, partner organisations and commissioners. Data collection methods included: document analysis, interviews (n = 45), workshops (n = 5) and focus groups (n = 11). This study was also supported by data collected by trained community researchers (n = 18). Framework analysis was conducted for within- and cross-case analysis. Results In the context of CAOs, the delivery of art, cultural and nature-based activities were found to be an important mechanism for developing trusted relationships with marginalised groups, who may lack trust in statutory services and health focused activities. Other facilitators to community engagement were the CAOs’ longevity, localness and co-location of services within a trusted and familiar place that connect people to personalised support. Barriers to scaling up included funding models as well as insufficient dialogue and understanding between CAOs and the local public health ecosystem. Conclusions CAOs have long term trusted relationships with disadvantaged communities and are influential in connecting individuals with projects and services. Findings suggest that the effectiveness of action to address inequality through art, cultural and nature-based activities could be improved if the role of CAOs was recognised more coherently in place-based public health plans. Key messages • Creative activities enable meaningful engagement with disadvantaged groups within place-based settings. • CAOs must be recognised more coherently in place-based strategies to reduce health inequalities.

The role of class stigma in socioeconomic inequalities in type 2 diabetes: The Maastricht Study

Abstract Background Low socioeconomic position (SEP) is a risk factor for type 2 diabetes mellitus (T2DM). An underlying mechanism behind socioeconomic health inequalities can be stigma, particularly classism. Studying the influence of class stigma in the context of (pre)diabetes and socioeconomic inequalities may shed light on the societal factors influencing diabetes. Methods Data from 1947 participants aged 49-88 who participated in the second phase of The Maastricht Study starting between November 2020 and April 2023 were used. SEP (education, income, occupation) and 6-item classism scale were measured through self-reported questionnaires. (Pre)diabetes was measured through an oral glucose tolerance test. We conducted multinomial logistic regression analyses to investigate the associations between SEP, classism, and diabetes status. Results 20.9% (N = 406) of the study sample had T2DM (Mage=69.8(±6.8) years; 31.3% women). People with low SEP had more often T2DM (e.g., income OR = 2.13, 95%CI:1.54-2.82) and reported perceived classism (e.g., education OR = 2.07, 95%CI:1.33-3.21) than people with high SEP. Classism was not statistically significantly associated with T2DM (OR = 0.78, 95%CI:0.48-1.29). Conclusions Social health inequalities are apparent in T2DM; however, our results suggest that class stigma might not be a major factor in underlying processes. Further research can investigate the role of chronic stress and intersection of multiple stigmas. Key messages • The underlying factors behind socioeconomic health disparities are complex. Social and psychological environment in low SEP should be investigated carefully. • Although low SEP is strongly associated with T2DM and perceived classism, class stigma might not be a major target in explaining socioeconomic pathways in diabetes.

Monitoring the level of health and inequality over time using the Population Health Performance Index

Abstract Background The Population Health Performance Index (PHPI) is a composite measure that combines average health outcomes and their distribution within a population, thereby allowing for a comprehensive assessment of population health and inequality. The aim of this study is to examine the extent to which the PHPI adds value to monitoring of health and inequality over time in comparison to absolute and relative inequality. Methods Data from the WHO Equity Monitor database on under-5 mortality disaggregated by wealth quintiles for Nepal, Ethiopia, Peru, Rwanda, and Zimbabwe were analysed using different years between 1994 and 2020. Descriptive comparative statistics were employed to assess trends in the PHPI and conventional pairwise measures of absolute and relative inequalities, with consideration of different weights for inequality aversion. Results PHPI trends correspond to the trend of absolute inequality in all five countries, although they exhibit less volatility over time. Relative inequality follows the trend of the PHPI in only two of the five countries (Ethiopia and Zimbabwe), reflecting the methodology utilised for the PHPI. PHPI scores vary based on different inequality aversion weights, highlighting the sensitivity of the index to methodological adjustments. Conclusions The PHPI demonstrates notable convergence of trends with conventional methods, thereby substantiating its utility as a comprehensive tool for the simultaneous measurement of health and inequality. As it is able to consider both absolute and relative inequality within its own calculations, the PHPI allows for independent analysis of its two key components. The PHPI facilitates a more nuanced understanding of population health and may be more easily understood by policymakers and other stakeholders. As it does not address the underlying causes of changes in health inequalities, further research is necessary to supplement monitoring activities. Key messages • PHPI is a valuable tool for health and inequality monitoring by integrating both average health and disparity in a single index, facilitating communication of trends over time. • The dual focus complements conventional methods with its multidimensionality and may enable stakeholders to assess health and inequalities in alignment with broader health policy objectives.

Exploring anxiety and depression trends: insights from the BELHEALTH cohort 2022-2024 in Belgium

Abstract Background The swift impact of the COVID-19 pandemic and ensuing restrictions on the mental health of the Belgian population prompted the need for a sustainable system to monitor its evolution. Repeated COVID-19 surveys were conducted between 2020 and 2022 to address this issue, followed by the launch of the BELHEALTH cohort project. Our study aims to analyze the trajectory of anxiety and depression at the post-pandemic period, using data from five waves of the BELHEALTH longitudinal surveys from October 2022 to March 2024. High-risk groups and the potential of social support and resilience to mitigate anxiety and depression were explored. Methods The BELHEALTH follow-up cohort of around 7,300 Belgian residents uses online surveys to assess anxiety (with the GAD-7), and depression (with the PHQ-9). The analyses were performed using linear mixed models on the 3,676 individuals who participated in all five waves. Results Preliminary results indicated that more people were affected by anxiety in October 2022 (16%) compared to June 2023 (14%), while depression rates were lower in October 2022 (13%) compared to February 2023 (14%) and March 2024 (15%). However, the trajectory of mental health varied across demographic subgroups, with worse outcomes observed among unemployed and younger individuals, as well as those living alone, in the Walloon Region (South of Belgium). Overall, people with a low level of resilience or a low level of social support exhibited higher odds of experiencing depression. Conclusions Reducing these social inequities in mental health necessitates the development of structural prevention measures and interventions at the regional level. These measures should target factors such as unemployment, which is particularly prevalent among younger individuals and those living in Wallonia. Additionally, fostering protective factors such as social support and resilience is crucial for mitigating mental health inequalities over time. Key messages • Monitoring mental health and its determinants remains crucial to identify and address social inequities, tailor interventions, and support vulnerable populations. • Unemployed, younger people, and those residing in the Walloon region are at particular risk.

Exploring racial inequalities in maternal mental health outcomes

Abstract Perinatal mental illness affects around 1 in 5 birthing people globally and is associated with adverse outcomes for those affected and their families. Such adverse outcomes are not inevitable and there is now good evidence for a range of both preventive and treatment interventions. There are well-documented inequalities in mental health outcomes across a range of social determinants, including race; such inequalities are also apparent during the perinatal period. There are also racial disparities in mental health care delivery during the perinatal period. Racial inequalities in perinatal mental health are now being recognized as key policy priorities in both the United States and the United Kingdom. This presentation will present routinely collected epidemiological data, investigating the drivers of these racial inequalities in access to perinatal mental health services and associated maternal and child outcomes. It also will present qualitative approaches to exploring current initiatives to reduce inequalities. Findings have the potential to inform the development of culturally sensitive interventions to promote equity in this area for underserved populations in the U.K., U.S., and elsewhere.

2.M. Scientific session: Economics of Mental Health in the interplay between health systems and public health

Abstract Mental health systems and services are essential components of the public health infrastructure, serving as frontline for prevention and intervention for health overall. Despite this, access to mental health services remains largely inadequate, with the OECD calculating that only about one in three people with mental health problems has access to quality treatment across 19 EU Member States. The economics of mental health play an important role in determining the allocation of resources, the accessibility of services and the overall effectiveness of interventions. Effective planning requires an understanding of population needs, service gaps and utilization patterns, in order to ensure equity and health improvement. In fact, the conceptualisation of the economic dimensions of mental health enables policymakers, practitioners, and stakeholders to make informed decisions that optimize resource utilization and maximize societal benefits. The proposed workshop will build on previous activities of the EUPHA Section on Public Health Economics at EPH, including the recent establishment of a working group on the economics of mental health. The aim of the meeting is to promote the adoption of best practices and methodologies in the conduct of economic studies on mental health. As such, the workshop will provide an opportunity to discuss the unique challenges of economic evaluation in this field and to present relevant ongoing activities by members of the Section and other invited experts. Key messages • Mental health, its distribution and at-risk populations influence resource allocation and policy decisions within mental health systems. • Tackling inequalities in mental health is essential for promoting health equity and social justice, requiring evidence-based interventions and policy initiatives to empower marginalized communities.

Social Inequalities in mental health service use and perceived helpfulness: A global analysis across 111 countries

Abstract Social inequalities in mental health are evident in the prevalence of mental health problems, but also the utilisation and patents’ perceived benefits of treatment. However, the extent of these disparities on a global scale and whether there are country-level differences in the predictors of mental health service use remain unknown. This study uses data from the Wellcome Global Monitor 2020, a nationally representative survey encompassing 111 countries and 117,088 individuals. We examine the association of socio-economic factors (such as household income and education), psycho-social factors (including stigma perception and trust in health professionals), and country-level variables (such as GDP, Gini coefficient, and health expenditure) with mental health service use and perceived effectiveness of treatment. Multi-level logistic regression models were employed for analysis. The utilisation of mental health professions of people with depression or anxiety symptomology is higher in HICs (predicted probability of 62% CI[0.60 - 0.65]) compared to LIMCs (predicted probability of 33% CI[0.31 - 0.34]). Higher country GDP (OR = 1.26 CI[1.08-1.47]) and health expenditure (OR = 1.11 CI[1.04-1.19] per percentage of health expenditure) are associated with higher treatment utilisation. On the individual level, those in the wealthiest quintile are more likely to engage with mental health professionals (OR = 1.25[1.14-1.36]) and perceive this treatment as highly beneficial (OR = 1.23[1.07-1.40]). Trust in healthcare practitioners and perceived stigma are also associated with mental healthcare use. This analysis shows strong patterns of mental healthcare use and perceived benefits depending on the wealth of the country, health expenditure and individual socio-economic status. Moreover, disparities in treatment utilization and effectiveness are also influenced by trust in healthcare professionals and perceived mental health stigma.

Inequities in child health in Luxembourg

Abstract Background In Luxembourg, despite its economic prosperity, 28.6 % of children are estimated to be at the risk of poverty. Research has shown that growing up with socioeconomic disadvantage is associated with worse physical and mental health in childhood. We explore the association of socioeconomic status with health, health behaviours and access to healthcare in Luxembourg for children up to age twelve. Methods We used data from 2014 to 2022 for 11-12 year old children from the Health Behaviour in School-aged Children (HBSC) survey as well as social security data from Luxembourg for a similar time period and children 0 to 12 years old. To assess socioeconomic status, we used information on self-perceived household wealth for the HBSC results and stratified health and health behaviours by well-off, average, or less well-off households. For the social security data, we stratified access to care indicators by equivalized household income quintiles. Results We found that physical activity levels, nutritional quality and daily routines such as eating breakfast and brushing teeth are significantly lower in children from less affluent families. For example, 61% of 11-12-year-old children from well-off families reported eating breakfast every day, but only 41% of children from less well-off families. Only 23% of 11-12 year olds from less affluent families rated their health as excellent, compared to 52% of children from affluent families. There were similarly large differences for multiple health complaints, with 63% of children from less affluent families reporting this indicator for psychosomatic problems, compared to 34% of children from affluent families. We did not find differences in the use of pre- and postnatal care visits. Conclusions Socioeconomic differences in child health, mental health and health behaviours are large, with children from poorer households being in worse physical and mental health and less likely to report positive health behaviours. Key messages • Many children in Luxembourg face socioeconomic challenges that are adversely associated with health and health behaviours. The underlying reasons require further attention to improve child health. • Children from poorer backgrounds are in significantly worse mental health than children from better off families in Luxembourg.

4.N. Scientific session: Equity in Child Health: Leveraging Universal Health Promotion Services for Families Amid Uncertainty

Abstract This workshop addresses the urgent need to foster resilience and equity in child health within the context of an increasingly uncertain Europe. Rapid societal changes, exacerbated by events such as the COVID-19 pandemic and heightened risks of conflict, climate change and economic instability, underscore the importance of nurturing environments where children can thrive despite challenging circumstances. The workshop aims to explore strategies for promoting well-being and addressing social inequalities in child health within the context of universal health promotion services, such as school health services and child health clinics. Objectives are to 1) Elucidate the importance and impact of universal health promotion services in addressing social inequalities and promoting equitable opportunities for all children, regardless of background or circumstance; 2) Identify actionable steps for interventions mitigating social inequalities and promoting equitable opportunities focusing on health literacy among parents with immigrant backgrounds; 3) Showcase successful models and initiatives in universal healthcare and health promotion services for children and families, emphasizing early intervention and standardized evaluation tools; and 4) Facilitate dialogue and knowledge exchange among professionals, policymakers, and stakeholders involved in child and adolescent health promotion. This workshop’s added value lies in its multidisciplinary approach, fostering collaboration for innovative solutions in child health resilience and equity. The coherence between presentations lies in their joint focus on addressing social inequalities in the context of universal health promotion services for children and families. Each presentation offers a unique perspective on these themes, contributing to a comprehensive understanding of the challenges and opportunities in child health promotion. • Hanne Nissen Bjørnsen’s presentation on the role of universal services in public health and addressing social inequality sets the stage by examining the structural factors contributing to disparities in child health outcomes. • Kirsti Riiseŕs presentation conveys the importance of user, stakeholder, and community involvement in creating culturally sensitive strategies for effective health promotion services in the context of health literacy among parents with immigrant backgrounds • Kristin Haraldstad’s presentation on Starting Right, an evidence-based assessment of children in municipalities healthcare centers, highlights the importance of early intervention and targeted support in mitigating health inequalities and promoting well-being. Format of the workshop: Three 10-minute presentations followed by a 20-minute moderated discussion to delve into empowerment and equity in child health, encouraging rich idea exchanges. Key messages • Leveraging universal health promotion services effectively empowers children and families while addressing social inequalities amidst periods of uncertainty. • Collaborative, user-centered approaches and evidence-based working strategies are key to promoting equity and building resilience in child health.

Intersectional inequalities in child social-emotional health: a case for proportionate universalism

Abstract Background Social-emotional difficulties in early childhood are associated with a range of outcomes across the life course and are related to socioeconomic factors. The aim of this study was to examine intersectional inequalities in social-emotional problems in preschool children relating to their parents’ income, education and country of birth in addition to investigating the public health implications. Methods This population-based study with a repeated cross-sectional design in the Västerbotten County of Sweden used the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) for children aged 3 in child health care services over the years of 2014-2018 and socio-economic information from national population registers. The effective sample of 8,823 individuals was analyzed using additive binomial regression in combination with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach to estimate risk differences for social-emotional problems across 27 intersectional groups and discriminatory accuracy. Results Average risk differences generally increased in the groups where multiple dimensions of social inequality intersected, with risk differences as high as 18% (95% CI 8 to 28%) and 25% (95% CI 14 to 37%) compared to the most advantaged category. The discriminatory accuracy of all three included regression models was estimated as moderate, but improved in a slight but statistically significant way with the addition of social inequalities. Conclusions This study increases our understanding of intersectional and social inequalities in social-emotional problems in preschool children. It supports the need for universal public health policies in addition to policies targeting more vulnerable groups when addressing this issue, consistent with the concept of proportionate universalism. An intersectional research perspective including discriminatory accuracy could increase our knowledge of health inequities and improve public health effectiveness. Key messages • Intersecting dimensions of social inequalities are associated with an increased risk of social-emotional problems in children aged 3. • Universal public health policies are needed in addition to policies targeting vulnerable population groups with regards to social-emotional problems in young children.

An intersectional approach on menstrual inequity as lived by women in circumstances of socioeconomic vulnerability in an urban and rural setting in Spain: a qualitative study

Since menstrual health and menstrual inequity are determined by social power structures, this study proposes to analyse, from an intersectional perspective, the experiences of menstrual inequity of women and people who menstruate (PWM) (≥18 years) under circumstances of socioeconomic vulnerability in an urban and rural setting in Catalonia (Spain), focusing on menstrual poverty, menstrual management and access to health care for menstrual health. An exploratory and interpretative qualitative study was conducted. Venue-based convenience sampling was carried out, recruiting women from a non-governmental organisation and a primary health care centre. Eighteen individual semi-structured interviews were conducted between October 2022 and February 2023. Data were analysed through reflexive thematic analysis. Analysis revealed that menstrual care was generally a distant preoccupation that revolved around circumstances of socioeconomic vulnerability, housing, and productive/reproductive work. Menstrual poverty, menstrual management and menstrual self-care challenges, barriers to accessing health care for menstrual health, and menstrual taboo, stigma and discrimination were commonplace and deepened by socioeconomic vulnerability. In this way, women’s menstrual experiences were rooted in intersecting axes of inequity, based on gender, race and class. Intersectional and critical participatory research, policy and practice are imperative to develop counter mechanisms that confront systems of privilege-oppression to modulate menstrual experience, health and equity.

Online Forum Conversations on Abortion in Poland: Navigating Medical, Emotional, and Legal Challenges

Abstract Background Abortion is a common medical procedure worldwide, but access is restricted in Poland, forcing many women to seek abortions without medical supervision. This can lead to health risks and reflects broader challenges regarding reproductive rights and healthcare. Methods We conducted a qualitative and quantitative analysis of online forums discussing abortion to understand the challenges faced by women in Poland. Data was gathered from popular abortion forums identified through Google searches, with a pilot study refining the research focus. Results A total of 13,397 responses from 370 threads across 4 forums were analyzed. The most prevalent theme was the ‘Abortion Process Progression,’ indicating a strong need for information and support. Discussions on ‘Emotional and Psychological Aspects’ and ‘Medical and Pharmacological Aspects’ highlighted the need for holistic care. This suggests that legal restrictions and fear of repercussions hinder women’s access to professional assistance, exacerbating health disparities and inequalities. Conclusions This study offers a general look at the abortion experiences of Polish women, revealing challenges that often go unnoticed by policymakers and healthcare professionals. By analyzing online forums, it uncovers nuanced issues such as the lack of access to medical supervision, information gaps, and emotional support, highlighting discrepancies between policy and needs. The findings call for decriminalizing abortion, launching educational campaigns to combat misinformation, and strengthening support systems, aligning Poland’s reproductive health services with European Union standards, ensuring women’s access to safe and supportive healthcare. Key messages • This study shows how Poland’s restrictive abortion laws push women to online forums, revealing medical, emotional, and logistical challenges, emphasizing the need for care and accurate information. • The research highlights the need for decriminalizing abortion, addressing misinformation, and support Poland’s reproductive health services with EU standards, ensuring safer care for women.