Health Inequalities Research Articles

Existing Health Inequities in the Treatment of Advanced and Metastatic Cancers.

This study aims to identify health inequities related to the medical treatment and supportive care of patients with advanced/metastatic cancer and recommend solutions to promote health equity. Despite robust strides in the development of therapeutic strategies for advanced and metastatic cancer, significant disparities in treatment access and implementation exist. Race, socioeconomic status, gender, and geography represent just a few of the individual-level factors which contribute to challenges in treatment administration, thorough evaluation of germline genetics and tumor genomics, and quality palliative and end-of-life care. Given the increasing complexity of cancer treatments and our enhanced understanding of tumor biology, efforts to uniformly provide equitable and high-level care to all patients are needed. In this review we will discuss factors that contribute to health inequities in patients with advanced and metastatic cancer diagnoses, highlighting opportunities for intervention, ongoing challenges in change implementation, and national and international society recommendations to eliminate disparities. Acknowledging existing inequities and engaging in multilevel discourse with key stakeholders is needed to optimize care practices to the benefit of all patients.

Periodontal diseases in Africa.

Periodontal diseases, a group of complex conditions marked by an excessive immune response and periodontal tissue destruction, are a global health concern. Since 1990, the incidence of these diseases has doubled, with Western sub-Saharan Africa experiencing the highest burden. Accurate diagnosis and case identification are crucial for understanding the etiology, features of disease, research, treatment and prevention. Modern perspectives on periodontal disease classification are based on commonality among those affected. However, current literature is often plagued by methodological inconsistencies and focused on disease mechanisms in European populations. Health inequalities in low- and middle-income countries (LMICs) are exacerbated by these challenges, with sub-Saharan Africa, and Nigeria specifically, facing unique difficulties such as clinical personnel shortages and limited research infrastructure. This review explored disparities in periodontal disease research, care and outcomes in African populations. We highlighted these disparities and identified the factors contributing to inequities in periodontal health outcomes. We further demonstrated the critical need for inclusive and equitable healthcare and research practices tailored to the unique challenges faced by diverse populations and regions with limited resources. Addressing these disparities is essential for ensuring that advancements in healthcare are accessible to all, thereby improving global oral health and general health.

A controlled trial comparing the impact of guided forest bathing or a mindful urban walk on heart rate, blood pressure, and mood in young Thai adults

Abstract In Thailand, cardiovascular disease and mental health cause a large health and economic burden, with 10% of Thai adults and 32% of adolescents reporting depression. Forest bathing (FB) (mindful nature walking) is growing in popularity globally as a preventative health intervention. Most FB research compares FB with a non‐active control of unguided urban walking, finding improved health and well‐being in FB but not the urban condition. This controlled trial offers a unique and robust comparison of guided FB with an active control of guided mindful urban walking. This is also the first study testing the acceptability and effectiveness of guided FB in Thailand. In a crossover design, heart rate, heart rate variability, blood pressure, and mood in 30 participants were compared before and after 1 h of guided FB and a guided mindful urban walk. MANOVA and t‐test analyses revealed that heart rate and blood pressure reduced in both conditions, but more in the mindful urban condition. Whilst negative mood was reduced in the FB condition but increased in the mindful urban condition. The study offers evidence for the promising health and well‐being benefits of both guided FB and mindful urban walking. Poor mental health and health inequalities are of increasing global concern, hence further research into the effectiveness of alleviating these difficulties through inexpensive interventions such as guided FB and mindful walking are encouraged. The study also offers the first data indicating that FB was acceptable and effective in a Thai population. Read the free Plain Language Summary for this article on the Journal blog.

Adaptation of the G-NORM (Gender norms scale) in Uganda: An examination of how gender norms are associated with reproductive health decision-making.

Restrictive gender norms exacerbate health inequalities all over the world. More specifically, they prevent women from seeking preventive health services, constrain women's economic empowerment, and are associated with reproductive health decision making. Gender norms, a subset of social norms, are dynamic and change over time. However, we lack data on how they are changing and how these changes affect health outcomes because current measures do not adequately capture the complex concept of gender norms. We originally developed and validated a gender norms scale, the G-NORM, in India. In this study, using cross-sectional data, we adapted the G-NORM from Southeast Asia (India and Nepal) to sub-Saharan Africa (Uganda) in four steps: 1. Formulation of new scale items (via qualitative analysis) 2. Cognitive Interviewing 3. Questionnaire Administration (n = 2422 women of reproductive age) and 4. Psychometric analysis (Confirmatory Factor Analysis). Like the original scale, descriptive norms and injunctive norms comprised two unique sub scales with high Cronbach's alphas (.80 & .92). Average scores differed depending on the type of norm suggesting that some gender norms are changing faster than others. Specifically, more equitable injunctive norms were associated with lower odds of partner-dominated contraceptive decision making but descriptive norms were not. Gender norms serve as a multi-faceted determinant of health and wellbeing and require measurement tools which account for their conceptual complexity. Validating the G-NORM in Uganda expands measurement options for researchers in the sub-Saharan African region working to change norms to reduce health inequalities or to understand the gender normative context before beginning a study.

Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey

BackgroundWorldwide, rural populations are recognized to be exposed to increased health challenges due to their living and working environment, socioeconomic status, and access to health services. According to the Romanian Country Health Profile 2023, approximately 46% of all deaths recorded in Romania in 2019 could be attributed to behavioral risk factors such as tobacco smoking, dietary risks, alcohol consumption and low physical activity. No data on rural versus urban areas are available to date, and research is needed to document health inequalities, identify barriers to health services, and explore solutions.MethodsThis study is an analysis of data collected during the Health Evaluation Survey carried out by the National Institute of Public Health in 2022 and aimed to reveal differences in health risk factors between rural and urban areas. The analysis was carried out under the methodological framework of the Health Evaluation Survey 2022, which is coordinated by the National Institute of Public Health.ResultsOur study’s objectively measured data revealed that the overall health profile of rural communities is characterized by lower education levels, lower incomes, and higher binge drinking rates than those of their urban counterparts. Additionally, rural inhabitants more often have high blood pressure, are more overweight and obese (per body mass index measurements) and have higher fasting plasma glucose. The health profile of the urban population revealed higher education levels and greater proportions of people with adequate monthly income, people with daily alcohol consumption, people who smoke, and people with hypercholesterolemia. Access to primary health care evaluated through proxy indicators was lower in rural areas but was relatively good overall.ConclusionsOur analysis of the health profile of rural communities revealed a greater prevalence of obesity and overweight, especially among women, and an increased prevalence of heavy drinking among men. Access to primary health care evaluated through proxy indicators is lower in rural areas but is relatively good overall. Lower education levels and the possibility of lower health literacy underpin the need for targeted health education campaigns. Sustainable strategies for rural health need to be identified, especially in the field of health promotion and disease prevention programs.Trial registrationThis study is observational research involving human participants where no interventions were applied to the study population.

Evaluating machine learning model bias and racial disparities in non-small cell lung cancer using SEER registry data.

Despite decades of pursuing health equity, racial and ethnic disparities persist in healthcare in America. For cancer specifically, one of the leading observed disparities is worse mortality among non-Hispanic Black patients compared to non-Hispanic White patients across the cancer care continuum. These real-world disparities are reflected in the data used to inform the decisions made to alleviate such inequities. Failing to account for inherently biased data underlying these observations could intensify racial cancer disparities and lead to misguided efforts that fail to appropriately address the real causes of health inequity. Estimate the racial/ethnic bias of machine learning models in predicting two-year survival and surgery treatment recommendation for non-small cell lung cancer (NSCLC) patients. A Cox survival model, and a LOGIT model as well as three other machine learning models for predicting surgery recommendation were trained using SEER data from NSCLC patients diagnosed from 2000-2018. Models were trained with a 70/30 train/test split (both including and excluding race/ethnicity) and evaluated using performance and fairness metrics. The effects of oversampling the training data were also evaluated. The survival models show disparate impact towards non-Hispanic Black patients regardless of whether race/ethnicity is used as a predictor. The models including race/ethnicity amplified the disparities observed in the data. The exclusion of race/ethnicity as a predictor in the survival and surgery recommendation models improved fairness metrics without degrading model performance. Stratified oversampling strategies reduced disparate impact while reducing the accuracy of the model. NSCLC disparities are complex and multifaceted. Yet, even when accounting for age and stage at diagnosis, non-Hispanic Black patients with NSCLC are less often recommended to have surgery than non-Hispanic White patients. Machine learning models amplified the racial/ethnic disparities across the cancer care continuum (which are reflected in the data used to make model decisions). Excluding race/ethnicity lowered the bias of the models but did not affect disparate impact. Developing analytical strategies to improve fairness would in turn improve the utility of machine learning approaches analyzing population-based cancer data.

Body Positivity, Physical Health, and Emotional Well-Being Discourse on Social Media: Content Analysis of Lizzo's Instagram.

Weight stigma is a fundamental cause of health inequality. Body positivity may be a counterbalance to weight stigma. Social media is replete with weight-stigmatizing content and is a driver of poor mental health outcomes; however, there remains a gap in understanding its potential to mitigate the prevalence and impact of harmful messaging and to promote positive effects on a large scale. We selected musical artist Lizzo, whose brand emphasizes body positivity and empowerment, for an instrumental case study on the discourse on social media and specifically Instagram. We focused on 3 domains, including body positivity, physical health, and emotional well-being. These domains challenge social norms around weight and body size and have the potential to positively affect the physical and psychological health of people with diverse body sizes. We evaluated posts by Lizzo, comments from Instagram users, and replies to comments over a 2-month period (October 11 to December 12, 2019). Two coders rated Lizzo's posts and Instagram users' comments for their sentiments on the 3 domains. Replies to Instagram users' comments were assessed for their reactions to comments (ie, did they oppose or argue against the comment or did they support or bolster the comment). Engagement metrics, including the number of "likes," were also collected. The final sample included 50 original posts by Lizzo, 250 comments from Instagram users, and 1099 replies to comments. A proportion of Lizzo's content included body positive sentiments (34%) and emotional well-being (18%); no posts dealt explicitly with physical health. A substantial amount Instagram users' comments and replies contained stigmatizing content including the use of nauseated and vomiting emojis, implications that Lizzo's body was shameful and should be hidden away, accusations that she was promoting obesity, and impeachments of Lizzo's health. In spite of the stigmatizing content, we also discovered content highlighting the beneficial nature of having positive representation of a Black woman living in a larger body who is thriving. Moreover, analysis of the discourse between users illustrated that stigmatizing expressions are being combated online, at least to some degree. This study demonstrates that Lizzo has exposed millions of social media users to messages about body positivity and provided more visibility for conversations about weight and shape. Future research should examine the extent to which body positive messages can lead to greater acceptance of individuals living in larger bodies. Instagram and other social media platforms should consider ways to reduce body-shaming content while finding ways to promote content that features diverse bodies. Shifting the landscape of social media could decrease stereotypes about weight and shape while increasing dialog about the need for greater acceptance and inclusion of people with diverse bodies.

Prevention and Treatment of HIV/AIDS: The Gates Foundation’s Role in Reducing Incidence and Extending Lives

HIV/AIDS remains a critical global health challenge, with profound social and economic impacts exacerbating existing inequalities and straining healthcare systems. Since its inception, the Bill & Melinda Gates Foundation has been at the forefront of combating this epidemic through its comprehensive and strategic approach. This review examines the foundation’s role in reducing HIV incidence and extending lives by focusing on prevention and treatment strategies. The foundation’s key initiatives include advancing scientific research and innovation, expanding access to antiretroviral therapy (ART), supporting pre-exposure prophylaxis (PrEP), and integrating HIV care with other health services. The foundation also emphasizes policy advocacy and global leadership, collaborating with international organizations to shape health strategies and reduce stigma. The review highlights the impact of these efforts in high-burden regions, particularly sub-Saharan Africa, and explores emerging challenges such as drug resistance and health inequities. Future directions include embracing innovative solutions, expanding access to advanced prevention methods, and ensuring the sustainability of HIV/AIDS programs in resource-limited settings. The Gates Foundation’s multifaceted approach serves as a model for global health initiatives, demonstrating how strategic investment and collaboration can drive significant progress in the fight against HIV/AIDS. Keywords: HIV/AIDS, prevention strategies, treatment programs, antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP).

The role of the primary healthcare research community in addressing the social and structural determinants of health: a call to action from NAPCRG 2023.

The need for effective primary healthcare to address social and structural determinants of health and to mitigate health inequalities has been well established. Here, we report on the international forum of the 2023 NAPCRG (formerly known as North American Primary Care Research Group) Annual Meeting. The aim of the forum was to develop principles for action for the primary healthcare research community on addressing social and structural determinants of health. From this forum, 10 key recommendations for the primary care research community were identified.

Building decolonial nursing curricula to address disparities in Indigenous women's maternal health

Social and health inequities and inequalities are rising all over the world (Smith, 2012; McGibbon et al., 2014; Chinn and Falk‐Rafael, 2018). Nursing students should therefore be educated to understand the multifaceted factors creating health inequities and the degree to which non-biological elements can be embodied and become biological (e.g., environmental stress leading changes in health.). The need for innovative undergraduate nursing curricula reform is apparent. The lack of nursing courses highlighting the effects of colonization, environmental justice, upstream structural and social determinants of health, globalization, and state violence must be addressed. Colonization, broadly speaking, characterizes the Eurocentric project to “civilize” the rest of the world utilizing various forms of violence (McGibbon et al., 2014). The persistent and ongoing reproduction and recurrence of colonialism, enacting cycles of disenfranchisement and oppression, creates significant inequities in physical, mental, and emotional health and well-being for historically marginalized groups of people (Smith, 2012). Because gaps in nursing curricula and outdated teaching practices may support persistent inequities, scholars and students have advocated for decolonization of nursing curricula (Smith, 2012; McGibbon et al., 2014; Chinn and Falk‐Rafael, 2018). This analysis utilizes decolonial theory and postcolonial feminism to suggest pathways to decolonize nursing curricula and pedagogy through decentering the colonial knowledge structures and practices that harm Indigenous health and wellbeing.

The global, regional, and national patterns of change in the burden of congenital birth defects, 1990–2021: an analysis of the global burden of disease study 2021 and forecast to 2040

Congenital birth defects (CBDs) present enormous challenges to global healthcare systems. These conditions severely impact patients' health and underscore issues related to socioeconomic development and healthcare accessibility and efficiency. Previous studies have been geographically limited and lacked comprehensive global analysis. This study provides global, regional, and national disability-adjusted life years (DALYs) data for four major congenital birth defects-congenital heart defects (CHD), neural tube defects (NTDs), digestive congenital anomalies (DCAs), and Down syndrome (DS) from 1990 to 2021, emphasizing health inequalities. The goal is to offer scientific evidence for optimizing resource allocation, focusing on high-burden populations, and reducing disease burden. This study systematically evaluated the global, regional, and national burden of CBDs and their changes from 1990 to 2021 using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021. To conduct a more focused analysis, four specific CBDs were selected: CHD, NTDs, DCAs, and DS. DALYs were used as the metric, combined with the sociodemographic index (SDI). Analyses included the slope index of inequality and concentration index to measure health inequalities, frontier analysis to estimate achievable outcomes based on development levels, decomposition analysis to identify drivers of disease burden changes, Joinpoint regression analysis to assess temporal trends, and the Bayesian age-period-cohort (BAPC) model to predict future disease burden trends. Compared to 1990, the global burden of the CBDs in 2021 showed a downward trend. Males had a higher burden than females, with the highest burden observed in low-SDI regions. When examining CHD, NTDs, DCAs, and DS specifically, trends in burden changes varied across different CBDs at the global, regional, and national levels. Frontier analysis revealed potential for burden improvement in various countries and territories. Decomposition analysis highlighted differences in disease burden drivers across SDI regions, showing the greatest improvement observed in low-SDI regions. Joinpoint regression analysis indicated a downward trend in DALYs burden across SDI regions, and BAPC model predictions suggested that the burden of CBDs will continue to decline in the future. CBDs pose a major challenge to global public health. Despite an overall decline in disease burden, health inequalities remain prominent, particularly in countries and territories with lower levels of development. Future public health interventions should focus on countries and territories with low levels of development by optimizing healthcare resource allocation, improving basic health infrastructure, enhancing health education, and reducing disease burden inequalities. Global collaboration and data sharing are essential to promote a lifecycle management model for CBDs research and treatment, advancing global health development. This study was supported by the National Natural Science Foundation of China (No. 82270310) and the Jiangsu Provincial Key Research and Development Program (No. BE2023662).

Addressing Social and Structural Determinants of Health in the Delivery of Reproductive Health Care: ACOG Committee Statement No. 11.

Social and structural determinants of health include historical, social, political, and economic forces, many of which are rooted in racism and inequality, that shape the relationship between environmental conditions and individual health. Unmet social needs can increase the risk of many conditions treated by obstetrician-gynecologists (ob-gyns), including, but not limited to, preterm birth, unintended pregnancy, infertility, cervical cancer, breast cancer, and maternal mortality. An individual health care professional's biases (whether overt or unconscious) affect delivery of care and may exacerbate and reinforce health disparities through inequitable treatment. Obstetrician-gynecologists and other health care professionals should seek to understand patients' health care decision making not simply as patients' individual-level behavior, but rather as the result of intersecting sociopolitical conditions, structural inequities, and social needs that create and maintain inequalities in health and health care. Recognizing the importance of social and structural determinants of health can help ob-gyns and other health care professionals to better understand patients, effectively communicate about health-related conditions and behavior, and contribute to improved health outcomes, including patients' experience of care and their trust in the health care system.

Secondhand racism: What we know and where to go regarding the relationship between vicarious racism and mental and physical health

AbstractRacism has long been established to be a significant determinant of racial inequalities in health among racially minoritized individuals. Most of this research, however, has been focused on individuals' direct perceived experiences of racism, and far less has been conducted on the relationship between indirect, vicarious experiences of racism and mental and physical health outcomes and behaviors. In this review, racism and vicarious racism are defined, and what is known about the relationship between vicarious experiences of racism and psychological and physical well‐being and health behaviors is documented. Like direct experiences of racism, research on vicarious experiences of racism suggests it is also adversely related to anxiety, depression, general psychological distress, and physiological health (e.g., allostatic load, cardiometabolic risk). Lastly, future directions for research and clinical practice are discussed. Understanding the intricate interplay between vicarious racism and overall mental and physical wellbeing is crucial for informing interventions aimed at mitigating the adverse mental health outcomes associated with experiences with racism.

Cross national patterns in educational inequalities in functional limitations among middle aged and older adults at two time points

IntroductionIn recent decades, the global population has aged rapidly while socioeconomic inequalities in health have widened, with older adults who are most disadvantaged experiencing the poorest health. Functional limitations are key predictors of disability and quality of life and are therefore considered an important measure of how well individuals and populations are aging. We determine if educational inequalities in functioning have widened over time and across countries. MethodsWe used data from five nationally representative surveys of aging, covering 14 high- and middle-income countries, with harmonized measures of functional limitations. We examined change over time in the number of functional limitations among adults aged 50-64 and 65 and older in each country as well as changes in educational inequality in functional limitations over time for both age groups. ResultsIn most high-income countries, the number of functional limitations decreased over time, but they increased in China and Mexico, with the largest increases occurring among adults 65 and older. Educational inequality in functional limitations among those aged 65 and older widened for several countries in our study, but for different reasons. In some countries, it widened due to increased limitations among the least-educated, while in others it widened due to declines in limitations among the most-educated. ConclusionGrowing educational inequality in functional limitations for older adults in several high- and middle-income countries suggests that, despite improvements in health and mortality, socioeconomic differences in functional health among older adults are widening.

Housing Australian Children: A Snapshot of Health Inequities in the First 2000 Days.

Housing is a critical social determinant of children's health. While individual pathways between housing and health are well evidenced, there has been less attention on the co-occurrence of housing disadvantages. We aim to identify typologies of children's housing disadvantage and describe the health inequities they generate. A cross-sectional latent class analysis (LCA) was conducted on 4355 Australian children aged 4 to 5years who participated in the Longitudinal Study of Australian Children. Nine binary indicators-dwelling tenure, external condition, affordability, stability, crowding, cleanliness, fuel poverty, and noise exposure-were used to generate latent housing typologies. Generalized linear models with robust standard errors described disparities in quality of life, injury, disability, and health service use across these housing typologies. Four distinct housing typologies were identified in this cohort: "good condition, affordable, and secure" (60%); "insecure" (11%); "crowded" (24%); and "unsuitable" (5%). Unsuitable housing, characterized by crowding, poor external conditions, and noise exposure, was more likely to be occupied by single-parent families, low-income households, and be headed by parents with low levels of education. Children in unsuitable housing lagged on quality of life indicators at preschool age (e.g., by 8.0 points on emotional functioning, 95% CI - 10.6, - 5.5), and underutilized primary healthcare services (e.g., prevalence ratio 0.76 for GP services, 95% CI 0.67, 0.87), compared to children in good quality housing. This finding supports the case for early intervention strategies that account for children's housing circumstances.

Workplace mortality risk and social determinants among migrant workers: a systematic review and meta-analysis.

Migrant workers, a population of 170 million, often work in dangerous or unhealthy working environments and are likely to suffer workplace injuries and labour abuses. However, the risk of mortality in migrant workers compared with local workers is unknown. We aim to synthesise global evidence on migrant worker mortality risk and identify social determinants to inform health and safety protections for migrant workers. We conducted a systematic review and meta-analysis of peer-reviewed literature to examine mortality outcomes among migrant workers and associated risk factors. We searched MEDLINE, Embase, PsycINFO, and Ovid Global Health for studies published between Jan 1, 2000, and Jan 17, 2023, reporting quantitative primary research in English. A broad definition of migrant worker was used, including any worker who is foreign-born (ie, international first-generation migrant workers), either in paid employment or self-employment. Internal migrants, second-generation migrants, and foreign health-care workers were excluded. The primary outcome was any reported mortality, including all-cause mortality, cause-specific mortality, suicide, homicide, and fatal occupational injury. We used meta-analysis to compare outcomes between migrant worker and local worker populations, and a random-effects model to calculate pooled estimates. We used narrative synthesis to develop a data-driven conceptual framework capturing the intersectional social determinants of mortality in migrant workers. The study protocol is registered on PROSPERO, CRD42023372893. Of 11 495 identified records, 44 were included in the systematic review, of which 11 studies were pooled in meta-analyses. Data were from 16 countries, most of which were high-income countries, and included 44 338 migrant worker deaths, including migrants from the agriculture, construction, mining, and service industries. Compared with local workers, migrant workers had a higher risk of fatal occupational injury (pooled relative risk 1·71, 95% CI 1·22-2·38; eight studies; I2=99·4%), and a lower risk of all-cause mortality (0·94, 0·88-0·99; three studies, I2=90·7%). Migrant workers were more likely to die from external causes of death (such as falls or assaults) than internal causes of death (such as respiratory or digestive diseases) compared with local workers, with migrant workers also more likely to die from work-related homicides, especially in the retail and sex industries, with some evidence of higher suicide rates among female migrant workers compared with female local workers. Influential social determinants for poor fatality outcomes include migration-related factors (such as lower language proficiency, undocumented status, and long duration of stay) and labour-related factors (such as precarious employment, labour migration policies, and economic deregulation policies). Migrant workers have a higher risk of workplace fatal injury despite being generally healthier than local workers, which could be explained by structural determinants such as precarious employment and inadequate safety protection. This health inequity must be urgently addressed through future interventions that account for migration-related and labour-related social determinants of health at the structural level, such as extending labour protection laws to migrant workers, and improving occupational health and safety and workplace conditions for this vital and growing workforce. UK Medical Research Council and National Institute for Health and Care Research.

LGBTQ+ Health Inequities in a Rural, Conservative Context: Alabama Compared with Other Southern States.

There are no statewide statistics regarding the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) Alabamians. To fill this gap, we used data collected by the Southern Equality Research and Policy Center to compare Alabama with other southern US states regarding the health and well-being of LGBTQ+ people. We tested for unadjusted differences between Alabama and other southern states using χ2 tests for dichotomous outcomes and the Wilcoxon rank-sum test for ordinal outcomes. Multivariate logistic models predicted dichotomous outcomes from an Alabama indicator, a continuous rurality variable, and a racial and ethnic minority indicator to control for differences in rurality and racial and ethnic composition; multivariate linear regression was used to approximate the point estimate of adjusted differences. Alabama and other southern states had statistically similar and high levels of abuse, harassment, and poor mental and physical health. Alabamians lived in ZIP codes with somewhat higher rural-urban commuting area code rurality scores (AL 1.76; South 1.70; P = 0.036, where 1 is the most urban category). More than one-fourth of Alabama respondents reported experiencing self-harming behaviors; one-third reported suicidal ideation (33.1%); more than half reported anxiety disorders (57.6%); more than two-thirds reported being depressed (69.2%); and 25% to 75% experienced or feared emotional and physical abuse because of their identity. Multivariate adjusted results were generally similar to unadjusted results. Alabama LGBTQ+ populations, who live in more rural settings than in most prior studies, experience markedly poor outcomes.

Reconsidering the City of New York Directive on Mental Health Involuntary Removals.

Homelessness is a visible manifestation of large-scale societal challenges, such as lack of affordable housing, poverty, and health inequities. Governments may miss opportunities to address these structural problems by removing people experiencing homelessness from public spaces. On 29 November 2022, after a press conference by Mayor Eric Adams, the city of New York issued a directive entitled Mental Health Involuntary Removals. The program authorized mental health providers and NYPD officers to take any person into custody who appears mentally ill and displays inability to meet basic living needs, even when no dangerous act has been observed. We reviewed the existing literature from 1973 to 2023 for studies, enacted legislation, state and federal policies, and interventions related to homelessness, mental health, and admission of people experiencing homelessness into psychiatric hospitals in the United States. We used academic databases, including PubMed, PsycInfo, and JSTOR for peer-reviewed articles, government reports, and policy analyses. Our search strategy included keyword combinations such as "homelessness and mental health," "policy interventions for homeless populations," and "health care services costs." We applied inclusion criteria focusing on reports and articles that directly address the intersectionality of homelessness, mental health policy, and psychiatric care. Homelessness and mental illness frequently intersect, creating complex challenges that require nuanced solutions. Forced hospitalization of people experiencing homelessness in New York City, while intended to address critical social and health care issues, carries a risk for significant long-term harm. This approach places strain on the mental health care system and may ultimately exacerbate the problems it purports to resolve.

Economic inequalities in adolescents’ internalising symptoms: longitudinal evidence from eight countries

Research, mainly conducted in Europe and North America, has shown an inequitable burden of internalising mental health problems among adolescents from poorer households. We investigated whether these mental health inequalities differ across a diverse range of countries and multiple measures of economic circumstances. In this longitudinal observational cohort study, we analysed data from studies conducted in eight countries (Australia, Ethiopia, India, Mexico, Peru, South Africa, the UK, and Viet Nam) across five global regions. All studies had self-reported measures of internalising symptoms using a validated scale at two timepoints in adolescence; a measure of household income, household consumption expenditure, or subjective wealth; and data collected between 2000 and 2019. Household income (measured in four countries), consumption expenditure (six countries), and adolescents' subjective assessment of household wealth (five countries) were measured in mid-adolescence (14-17 years). The primary outcome (internalising symptoms, characterised by negative mood, affect, and anxiety) was measured later in adolescence between age 17 and 19 years. Analyses were linear regression models with adjustment. Effect estimates were added to random-effects meta-analyses to aid understanding of cross-country differences. The overall pooled sample of eight studies featured 18 910 adolescents (9568 [50·6%] female and 9342 [49·4%] male). Household income had a small or null association with adolescents' internalising symptoms. Heterogeneity (I2 statistic) was 71·04%, falling to 39·71% after adjusting for baseline symptoms. Household consumption expenditure had a stronger association with internalising symptoms (decreases of 0·075 SD in Peru [95% CI -0·136 to -0·013], 0·034 SD in South Africa [-0·061 to -0·006], and 0·141 SD in Viet Nam [-0·202 to -0·081] as household consumption expenditure doubled). The I2 statistic was 74·24%, remaining similar at 74·83% after adjusting for baseline symptoms. Adolescents' subjective wealth was associated with internalising symptoms in four of the five countries where it was measured. The I2 statistic was 57·09% and remained similar after adjusting for baseline symptoms (53·25%). We found evidence for cross-country differences in economic inequalities in adolescents' internalising symptoms, most prominently for inequalities according to household consumption expenditure. Subjective wealth explained greater variance in symptoms compared with the objective measures. Our study suggests that economic inequalities in adolescents' mental health are prevalent in many but not all countries and vary by the economic measure considered. Variation in the magnitude of inequalities suggests that the wider context within countries plays an important role in the development of these inequalities. Wellcome Trust.

The Role of Health Systems in Cross-Sector Collaboration in Addressing Social Determinants of Health and Promoting Health and Well-Being.

The articles featured underscore the critical role of trust, strategic planning, and cross-sector partnerships in addressing health inequities, while emphasizing the need for further research on sustainable and cost-effective collaboration models. Tocco and colleagues from Northwell Health describe the formation of the Health Equity Taskforce (HET), initially aimed at equitable COVID-19 vaccine distribution on Long Island. The HET has since expanded to address broader health disparities, focusing on community involvement, strategic partnerships, and sustainability. Nemiroff and colleagues discuss collaborations with community partners and payors to address social determinants of health in underserved populations, highlighting opportunities that can facilitate collaborations such as the New York State's Medicaid 1115 Demonstration Waiver.