Key Social Determinants Of Health Research Articles

Precarious employment and mental health in European welfare state regimes: a multilevel approach

Abstract Background Precarious employment (PE) is a key social determinant of health that is, in turn, shaped by the broader institutional framework of the country in which it is embedded. At the same time, evidence sustains that welfare state regimes (WSRs) have a decisive role in determining people's health. However, the interaction effect between them is yet to be studied from a public health perspective. This article examines how WSRs, PE and mental health (MH) relate in Europe, and whether this relationship differs between women and men. Methods Data were derived from the European Working Conditions Survey 2015. PE was measured through the Employment Precariousness Scale for Europe (EPRES-E), validated for comparative research in 22 European countries, which were classified into five WSRs (Bismarckian, Anglo-Saxon, Scandinavian, Southern and Central-Eastern). MH was measured through the WHO-5 Well-Being Index. In a sample of 30,795 formal employees, we performed multilevel poisson regression models stratified by women and men. Results Results show a gradual association between PE quartiles and poor MH (PR Q2=1.37 CI95% [1.13-1.65], Q3=1.86[1.51-2.30], Q4=2.96[2.31-3.81] men; PR Q2=1.15[0.97-1.37], Q3=1.48[1.22-1.79], Q4=2.06[1.64-2.58] women) after adjusting for control variables. Further, the Scandinavian WSR displayed an overall protective effect for MH among men, as compared with the Bismarckian (PR = 0.58[0.34-0.99]). Regarding the interaction effects, these were only significant in the Central-Eastern WSR, which was found to boost the negative association between PE and MH among women (PR = 1.17[1.03-1.33]). Conclusions These findings point to a differential effect of WSRs on the negative relationship between PE and MH according to gender. Key messages European welfare state regimes unequally affect the negative association between precarious employment and mental health. This differential is also gender-based, since the Central-Eastern regime further deteriorates the mental health of precarious employees only among women, as compared to the Bismarckian.

Health experiences of child migrants in the Western Pacific region

ABSTRACT Migration is a key social determinant of health affecting children’s life chances and health outcomes. Yet, relatively little is known about young migrants’ own health experiences. This paper reports findings from a systematic review examining the health experiences of children who migrated in the Western Pacific region. A systematic search of the peer-reviewed literature from 2007–17 was conducted using MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, Web of Science, ASSIA and IBSS. Included articles reported data generated with children up to 18 years and who had migrated across international borders to the Western Pacific region (predominantly Australasia). The Mixed Methods Appraisal Tool was used to assess study quality. Eleven of 499 articles identified were included in the review and focused on three areas: diet and body size; mental health; and social integration. The review exposes the paucity of research on the health experiences of child migrants in the Western Pacific region. More child-centred research that examines the health-related impacts of migration on young people, and from their own perspectives, is urgently needed.

Addressing financial strain through a peer-to-peer intervention in primary care.

Financial strain is a key social determinant of health. As primary care organizations begin to explore ways to address social determinants, peer-to-peer interventions hold promise. Our objective was to evaluate a peer-to-peer intervention focussed on financial empowerment delivered in primary care, in partnership with a social enterprise. This intervention was hosted by a large primary care organization in Toronto, Canada. Participants were recruited within the organization and from local services. We organized three separate groups who met over 10 weekly in-person, facilitated sessions: millennials (age 19-29) no longer in school, precariously employed adults (age 30-55) and older adults near retirement (age 55-64). We applied principles of adult education and peer-to-peer learning. We administered surveys at intake, at exit and at 3 months after the intervention, and conducted three focus groups. Fifty-nine people took part. At 3 months, participants had sustained higher rates of optimism about their financial situation (54% improved from baseline), their degree of control (55% improved) and stress around finances (50% improved). In focus groups, participants reported greater understanding of their finances, that they were not alone in struggling with finances, and that it was useful to meet with others. One group continued to meet for several months after the intervention. In this study, a peer-to-peer intervention helped address a key social determinant of health, likely through reducing stigma, providing group support and creating a space to discuss solutions. Primary care can host these interventions and help engage potential participants.

Financial health as a measurable social determinant of health.

Financial health, understood as one's ability to manage expenses, prepare for and recover from financial shocks, have minimal debt, and ability to build wealth, underlies all facets of daily living such as securing food and paying for housing, yet there is inconsistency in measurement and definition of this critical concept. Most social determinants research and interventions focus on siloed solutions (housing, food, utilities) rather than on a root solution such as financial health. In light of the paucity of public health research on financial health, particularly among low-income populations, this study seeks to: 1) introduce the construct of financial health into the domain of public health as a useful root term that underlies other individual measures of economic hardship and 2) demonstrate through outcomes on financial, physical and mental health among low-income caregivers of young children that the construct of financial health belongs in the canon of social determinants of health. In order to extract features of financial health relevant to overall well-being, principal components analysis were used to assess survey data on banking and personal finances among caregivers of young children who participate in public assistance. Then, a series of logistic regressions were utilized to examine the relationship between components of financial health, depression and self-rated health. Components aligned with other measures of financial health in the literature, and there were strong associations between financial health and health outcomes. Financial health can be conceived of and measured as a key social determinant of health.

Diverse students collaborating to address social determinants of health using listening sessions.

In this article, a Nursing Workforce Diversity grant-funded project examined the social determinants of health (SDH) including diverse high school and baccalaureate nursing students. All involved students were from educationally and/or economically disadvantaged backgrounds and/or underrepresented minority groups. The purpose of this article is to report the project outcome data and analysis gathered from students' experiences of SDH, using the collaborative method, listening sessions. The project staff and student nurses discussed SDH with high school students, who then identified and prioritized key SDH in their neighborhoods during a series of facilitated listening sessions in their schools. Initial analysis included reviewing, with the students, the notes taken during the sessions, resulting in a list of SDH to address. As a secondary analysis, the listening session tapes were transcribed and independently coded and examined by project staff. Six themes evolved that illustrate the depth of understanding of the complex challenges of SDH experienced by students in their local communities. Based on student-determined priorities, the project staff developed programs to meet the identified SDH needs at both high schools. Nursing and other health professionals are in ideal positions to collaborate with schools to create programming interventions for addressing SDH effectively into the future.

Armed conflict as a determinant of children malnourishment: a cross-sectional study in The Sudan

BackgroundChildren’s nutritional status influences their physical, socioemotional and cognitive development throughout the life course. We aimed to determine the role of armed conflict on the prevalence of childhood malnourishment in The Sudan, and understand the underlying mechanisms using a framework based on the social determinants of health.MethodsWe analysed cross-sectional data from the 2014-Sudan Multiple Indicator Cluster Survey (n = 14,081) to compare the prevalence of malnourishment in states undergoing armed conflict and states free of conflict. Four-level multilevel multivariate modelling was conducted to identify the contribution of the social determinants of malnourishment in explaining the role of armed conflict in child health, with conflict status as the central predictor and progressive adjustments for child-, household- and cluster- and state-level predictors.ResultsArmed conflict is strongly associated with greater risk of severe and moderate underweight among children under-5. Adjusting for key social determinants of health reduced the strength of the association between armed conflict and risk of underweight, but there is statistical evidence of association between armed conflict and risk of severe underweight (OR: 1.60, 95%CI: 1.03–2.49 for the low intensity group).ConclusionConflict-exposed children are particularly vulnerable to malnourishment, and this association is mostly explained by key socio-demographic factors. With the prolonged political instability in The Sudan, sustainable nutritional interventions are necessary to ease hard conditions in conflict-exposed states, and also among disadvantaged families in conflict-free regions.

Abstract 10: Socioeconomically Disadvantaged Medicare Beneficiaries Had Worse One Year Clinical Outcomes But Lower Total Annual Costs of Care

Background: Recent data suggest that cost prediction models in the private insurance setting may systematically underpredict costs in high-risk subgroups due to uneven access to health care. This may lead to disparities in allocation of preventive services and other interventions. However, whether these patterns persist in an older population with higher rates of comorbidity and chronic disease is uncertain. Objective: We set out to determine whether socially disadvantaged Medicare beneficiaries had disproportionately low costs compared to their clinical outcomes, which might serve as a marker for inadequate access to care. Methods: We calculated one year all cause and CV hospitalization, death, and total costs for Current Medicare Beneficiary Survey participants from 2016-2017 (N=3,614). We used logistic and linear regression, as appropriate, to examine the relationship between key social determinants of health and clinical outcomes, as well as annual costs of care. Results: For age and clinical risk, there was directional agreement between adverse events and annual cost. For example, those in the highest tertile of comorbidity index had the highest rates of adverse outcomes as well as higher costs compared to those in mid and low tertiles (Incidence Rate Ratio (IRR) for all-cause and cardiovascular hospitalization =3.29 and 4.37 respectively, OR for death=3.35; cost differential $8641, p<0.001 for all). However among the poor, minorities, and those with low education, adverse clinical outcomes were inversely related to cost. After multivariable adjustment, blacks/Hispanics had higher rates of CV hospitalization (IRR 1.78, p=0.012), but similar annual costs ($-336, p=0.77) compared to whites. This pattern of similar annual costs, despite higher rates of adverse outcomes, was also observed for those whose income was <25,000/year, those who had less than a college education, and those reporting living at an income poverty ratio of <100% (difference in costs $-373, $-712, & $-638, respectively, p>0.05). Conclusions: A paradoxical relationship was observed between adverse outcomes and cost among racial/ethnic minorities, and those from low socioeconomic groups. Because of systematic differences in access to care, cost may not be an appropriate surrogate for predicting clinical risk among the poor or other vulnerable populations, and algorithms that are based on cost alone may lead to inadequate risk prediction.

Low Human Papillomavirus Literacy Among Asian-American Women in California: an Analysis of the California Health Interview Survey.

Asian-Americans are one of the fastest growing minority groups in the USA, and the literature notes high rates of human papillomavirus (HPV). In this study, we aimed to address whether key social determinants of health, especially health literacy, in combination with English language proficiency, and immigration status, were key factors in HPV knowledge and awareness among Asian-Americans. The data was collected from the California Health Interview Survey (CHIS). The study population consisted of Asian adult females from 18 to 65years of age, with a sample size of 2050 representing a population of 1,552,710. Survey-weighted descriptive, bivariate, and multivariable Poisson regression were conducted with alpha less than .05 to denote significance. Nearly 45% of the population reported that they never heard of HPV, while 14% reported thinking HPV can cause AIDS, and 13% reported that HPV can go away on its own. HPV knowledge, however, was varied by Asian-American ethnicity as well as being foreign-born. Survey-weighted multivariable robustPoissonregression results show that, when compared with Japanese subgroup, Chinese, South Asians, and Koreans were less likely to have heard of HPV. Having heard of HPV was 31% lower among Asian-Americans who were foreign-born, as compared with those who were US-born. Foreign-born Asian-Americans were 196% more likely to think HPV causes AIDS. Ever having heard of HPV was also associated with low English language proficiency (70% lower), low health literacy (45% lower), and a combination of both (55%). While, those with low English language proficiency understood HPV is a sexually transmitted infection, a substantially high number associated it with AIDS. Interventions towards increasing health literacy among Asian Americans are imperative in order increase HPV vaccination rates to reduce cervical cancer rates/deaths.

Social Determinants of Health and the Hospitalized Child.

KP, a 2.5-year-old infant with cachexia, recently was admitted to our hospital. A year ago, the hospitalist team treated her for sequelae of Zika virus exposure: microcephaly, central diabetes insipidus, and failure to thrive. Sadly, here she was again, weighing less than her discharge weight when she was 18 months old. Her standardized weight for age had plummeted from an already poor −2.5 to an abysmal −5.5. How had our medical system failed this child? KP’s mother had dual US and Dominican citizenship, but was homeless and lacking many social supports in the United States. When her medically complex child was born, her social safety net collapsed. She realized she could not continue to bounce around between homes with such a medically fragile child. She had applied for Section 8 housing but had no idea when it would be approved, so she did the only thing that seemed reasonable: move back to the Dominican Republic to live with her parents. She ran out of desmopressin acetate (DDAVP) for her child in 3 months. She was forced to replace her child’s prescribed formula with powdered milk. She was hospitalized multiple times for aspiration pneumonia. KP returned to the United States with her mother, malnourished and weak, when their housing voucher was approved. Her health had dramatically declined, all because of housing insecurity and other key social determinants of health (SDOH). SDOH are “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”1 There is some variability in opinion on what constitutes the SDOH roster, but the determinants generally include economic stability, education, social and community context, health and health care, neighborhood and built environment, limited English proficiency, immigration status, transportation barriers, racism and bias, household …

Special Education Disparities Are Social Determinants of Health: A Role For Medical-Legal Partnerships.

Education is a key social determinant of health. The federal Individuals with Disabilities Education Act (IDEA) purportedly affords children the right to a free and appropriate education. Yet, racial, ethnic, and economic disparities exist regarding appropriate identification and classification of children with needs for special education, and access to services. This article first highlights gaps and disparities in special educational services, and their structural linkage to poverty. The second section describe the first years of a medical-legal collaboration between a University Center of Excellence in Developmental Disabilities (UCEDD) and Fordham University, focused on special education. The collaboration's interdisciplinary training activities increased practical knowledge for law students and UCEDD clinicians. A legal clinic for UCEDD families enabled Fordham students to apply their skills. Because social determinants of health often lie beyond the medical domain, interdisciplinary collaborations are needed to remediate them.

SPIRITUALITY IN CHRONIC PAIN SELF-MANAGEMENT: LOWER USE BUT EQUAL IMPORTANCE IN OLDER AFRICAN AMERICANS

Spirituality is a key social determinant of health for African Americans (AAs) and strongly impacts management of chronic pain. Older AAs (average age 68± 12.37) from urban and rural communities completed questionnaires (N= 110) and audio-recorded, semi-structured individual interviews (N= 18) describing osteoarthritis pain self-management. Prayer was used by 42% of AAs, with substantially fewer attending church (23.6%), watching religious television or reading the Bible/Christian literature (20.9%), listening to gospel music (18.2%), and laying of hands (8.2%). Interestingly, prayer and church attendance were the only pain strategies rated by more participants as very helpful. Regardless of religiosity, most AAs believed that spirituality was “an important aspect, whether we realize it always or not”. Specifically, prayer was considered “number one… ‘cause I know it’s gonna be all right once I do pray…prayer help heal the pain”. Spiritual strategies remain integral for chronic pain self-management despite lower than expected use among AAs.

Associations of Social Determinants of Health and Self-Reported Visual Difficulty: Analysis of the 2016 National Health Interview Survey

ABSTRACTPurpose: To determine the association of selected social determinants of health (SDH) assessed by the National Health Interview Survey (NHIS) among adults with visual difficulty.Methods: Data from adults 18 years of age and older relevant to self-reported visual difficulty were extracted from the 2016 NHIS dataset. A multivariate logistic regression model was used to determine associations between self-reported visual difficulty and key social determinants of health identified by the Kaiser Family Foundation and American College of Physicians. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI).Results: Self-reported visual difficulty was significantly associated with lower educational attainment (OR 1.54; 95% CI, 1.30–1.81), having healthcare coverage through Medicaid (OR 1.44; 95% CI, 1.23–1.67), food insecurity (OR 1.75; 95% CI, 1.54–1.99), problems with paying medical bills (OR 1.60; 95% CI, 1.40–1.83), trouble finding a doctor (OR 1.49; 95% CI, 1.19–1.86), cost-related medication underuse (OR 1.72; 95% CI, 1.54–1.93), and identification as a non-heterosexual male (OR 1.82; 95% CI, 1.21–2.73). Those who were employed were at lower risk of visual difficulty compared to those who were looking for work or not working (OR 0.79; 95% CI, 0.71–0.89).Conclusion: A subset of SDH as evaluated by the NHIS are positively associated with self-reported visual difficulty. If validated, these results could inform future public health interventions that may reduce the incidence and burden of visual difficulty.

Social determinants of health and survivorship in parotid cancer: An analysis of the National Cancer Database

Given the rarity of parotid cancer, there is relatively few data published regarding outcomes. Utilizing the large sample population of the National Cancer Database (NCDB), we aim to examine the relationship between two key social determinants of health, demographics and socioeconomic status (SES), and parotid malignancy survival rates. Our analytic sample consists of patients with a diagnosis of primary malignancy of the parotid gland between 2004 and 2012 in the NCDB. We used univariable and multivariable Cox proportional hazard models to evaluate the relationship between overall survival rate and two key social determinants of health: demographics and SES. 15,815 cases met inclusion criteria. Average age was 60.1 years and 8255 were male (52.2%). Median overall survival was 121 months with 5-year overall survival of 67.4%. Male sex and older age at diagnosis were associated with poorer overall survival (p < 0.0001). We found that Asian Americans compared to whites had better overall survival (HR 0.75; 95% CI [0.58-0.95]). Black patients had improved survival compared to whites on univariate (HR 0.71; 95% CI [0.64-0.79]); but not multivariate analysis. Hispanic ethnicity and higher education level were protective (HR 0.76 95% CI [0.63-0.91] and HR 0.84 95% CI [0.74-0.96], respectively). We found no significant survival association based on income level. In this national sample of patients with parotid malignancy, a rare form of cancer, we found a significant correlation between important social determinants of health and overall survival rate. Females, Asian-Americans, Hispanics, and patients with higher education level have better overall survival.

HIV and employment among Black men who have sex with men in Baltimore

ABSTRACTEmployment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22–0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Psychological and social determinants of health, antiretroviral therapy (ART) adherence, and viral suppression among HIV-positive black women in care

ABSTRACTBlack women are disproportionately affected by HIV, accounting for 61% of women diagnosed in 2016. Black women with HIV are less likely to be adherent to antiretroviral therapy (ART) and virally suppressed compared to women of other racial/ethnic groups. We analyzed 2013–2014 data from 1703 black women patients in the Centers for Disease Control and Prevention’s Medical Monitoring Project to examine whether select psychological and social determinants of health (SDH) factors were associated with ART adherence and viral suppression. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to examine correlates of ART adherence and viral suppression. Women who had not been incarcerated in the past 12 months (aPR = 1.24; CI: 1.04–1.48) and had not experienced discrimination in a health care setting since their HIV diagnosis (aPR = 1.06; 1.00–1.11) were slightly more likely to be adherent to ART. Women who lived above the federal poverty level were more likely to be virally suppressed during the past 12 months (aPR = 1.09; CI: 1.01–1.18). More research is warranted to identify the best strategies to create health care settings that encourage black women’s HIV care engagement, and to address other key SDH and/or psychological factors.

The Impact of Social Determinants of Health on Hospitalization in the Veterans Health Administration

This study aims to assess the effect of individual and geographic-level social determinants of health on risk of hospitalization in the Veterans Health Administration primary care clinics known as the Patient Aligned Care Team. For a population of Veterans enrolled in the primary care clinics, the study team extracted patient-level characteristics and healthcare utilization records from 2015 Veterans Health Administration electronic health record data. They also collected census data on social determinants of health factors for all U.S. census tracts. They used generalized estimating equation modeling and a spatial-based GIS analysis to assess the role of key social determinants of health on hospitalization. Data analysis was completed in 2018. A total of 6.63% of the Veterans Health Administration population was hospitalized during 2015. Most of the hospitalized patients were male (93.40%) and white (68.80%); the mean age was 64.5 years. In the generalized estimating equation model, white Veterans had a 15% decreased odds of hospitalization compared with non-white Veterans. After controlling for patient-level characteristics, Veterans residing in census tracts with the higher neighborhood SES index experienced decreased odds of hospitalization. A spatial-based analysis presented variations in the hospitalization rate across the Veterans Health Administration primary care clinics and identified the clinic sites with an elevated risk of hospitalization (hotspots) compared with other clinics across the country. By linking patient and population-level data at a geographic level, social determinants of health assessments can help with designing population health interventions and identifying features leading to potentially unnecessary hospitalization in selected geographic areas that appear to be outliers.

The impact of racism on the future health of adults: protocol for a prospective cohort study

BackgroundRacial discrimination is recognised as a key social determinant of health and driver of racial/ethnic health inequities. Studies have shown that people exposed to racism have poorer health outcomes (particularly for mental health), alongside both reduced access to health care and poorer patient experiences. Most of these studies have used cross-sectional designs: this prospective cohort study (drawing on critical approaches to health research) should provide substantially stronger causal evidence regarding the impact of racism on subsequent health and health care outcomes.MethodsParticipants are adults aged 15+ sampled from 2016/17 New Zealand Health Survey (NZHS) participants, sampled based on exposure to racism (ever exposed or never exposed, using five NZHS questions) and stratified by ethnic group (Māori, Pacific, Asian, European and Other). Target sample size is 1680 participants (half exposed, half unexposed) with follow-up survey timed for 12–24 months after baseline NZHS interview. All exposed participants are invited to participate, with unexposed participants selected using propensity score matching (propensity scores for exposure to racism, based on several major confounders). Respondents receive an initial invitation letter with choice of paper or web-based questionnaire. Those invitees not responding following reminders are contacted for computer-assisted telephone interview (CATI).A brief questionnaire was developed covering current health status (mental and physical health measures) and recent health-service utilisation (unmet need and experiences with healthcare measures). Analysis will compare outcomes between those exposed and unexposed to racism, using regression models and inverse probability of treatment weights (IPTW) to account for the propensity score sampling process.DiscussionThis study will add robust evidence on the causal links between experience of racism and subsequent health. The use of the NZHS as a baseline for a prospective study allows for the use of propensity score methods during the sampling phase as a novel approach to recruiting participants from the NZHS. This method allows for management of confounding at the sampling stage, while also reducing the need and cost of following up with all NZHS participants.

Social exclusion, self-rated health and depression among older people in China: Evidence from a national survey of older persons

BackgroundIt is well established that social exclusion is a key social determinant of health; however, such association between social exclusion and health outcomes among older people remain a relatively under-researched area. This paper explores the effects of four dimensions of social exclusion on self-rated health and depression among older people in China. MethodsThis paper includes 8038 individuals aged 60 and over from the first wave national multi-stage probability sample (2014) from the China Longitudinal Aging Social Survey (CLASS). Descriptive univariate information for individual variables and four dimensions of social exclusion are presented. Multinomial and binary logistic regression models are used to examine the associations between social exclusion and self-rated health and depression. ResultsOlder people who were in the lower level of exclusion from social relationships or subjective feelings of exclusion were significantly less likely to report fair or poor self-rated health than people in the higher level of exclusion (lower level of exclusion from social activities was significantly associated with being less likely to report poor SRH only). Older people who were in the lower level of subjective feeling of exclusion or exclusion from financial products were significantly less likely to report depression. ConclusionsDifferent dimensions of social exclusion have different effects on self-rated health and depression. Social policies need to reflect this and efforts of services could usefully be oriented to prevent multi-dimensions of social exclusion. Ultimately, such policies should have the potential to enhance the health of older people in China.

Routine collection of sexual orientation and gender identity data: a mixed-methods study.

Sexual orientation and gender identity are key social determinants of health, but data on these characteristics are rarely routinely collected. We examined patients' reactions to being asked routinely about their sexual orientation and gender identity, and compared answers to the gender identity question against other data in the medical chart on gender identity. We analyzed data on any patient who answered at least 1 question on a routinely administered sociodemographic survey between Dec. 1, 2013, and Mar. 31, 2016. We also conducted semistructured interviews with 27 patients after survey completion. The survey was offered to 15 221 patients and 14 247 (93.6%) responded to at least 1 of the sociodemographic survey questions. Most respondents answered the sexual orientation (90.6%) and gender identity (96.1%) questions. Many patients who had been classified as transgender or gender diverse in their medical chart did not self-identify as transgender, but rather selected female (22.9%) or male (15.4%). In the semistructured interviews, many patients expressed appreciation at the variety of options available, although some did not see their identities reflected in the options and some felt uncomfortable answering the questions. We found a high response rate to questions about sexual orientation and gender identity. Fitting with other research, we suggest using a 2-part question to explore gender identity. Future research should evaluate the acceptability and feasibility of administering these questions in a variety of care settings. These data can help organizations identify health inequities related to sexual orientation and gender identity.

Impact of income-based policies on population health and health inequalities in Scotland: a modelling study

BackgroundImproving health and reducing health inequalities are important joint policy objectives. Income is a key social determinant of health, but robust evidence about the relative impacts of redistributive policies is rare. In a modelling study, we aimed to assess the effects on population health and health inequalities of income-based policies in Scotland. MethodsEUROMOD, a detailed tax–benefit microsimulation model, was used to estimate income change for a representative sample of Scottish households from the Family Resources Survey 2014–15 (n=2871). Income change was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation. Triple I, a health inequalities scenario modelling tool, was used to estimate projected impacts of income-based policies, including two Citizen Basic Income (CBI) schemes (basic scheme and one with additional payments for disabled) on premature mortality (<75 years) and inequalities after 5 years, compared with baseline. Implications for government revenue were also estimated. FindingsThe best policies for achieving both policy objectives were increases to means-tested benefits (−4·1% premature mortality, −21·7% Relative Index of Inequality [RII]), increases to benefits devolved to the Scottish Government (−1·6%, −6·1%), and the introduction of a mandatory living wage (−2·2%, −5·2%). The increase in household incomes in the most deprived areas under these three policies was ten, five, and three times higher than in the least deprived areas, respectively. The CBI schemes had a substantial narrowing effect on inequalities (−11·5% RII basic scheme, −17·9% CBI with additional payments), and a modest effect on premature mortality (−0·3%, −0·8%). Increases to benefits were most cost-effective at improving health, whereas the CBI policies were most cost-effective at reducing inequalities. InterpretationPolicies that affect incomes have the potential for substantial effects on health and health inequalities in Scotland. We estimated that the most effective policies for reducing health inequalities were those that disproportionately increased incomes in the most deprived areas. The modelling is subject to various assumptions and sources of uncertainty, but nonetheless highlights the importance of applying an inequalities lens to income-based policy options. FundingNone.