Large Inequalities Research Articles

What constitutes the social in (social) sustainability? Community, society and equity in South African water governance

ABSTRACT This article explores the question of what constitutes the “social” in (social) sustainability. It applies a governmentality perspective and focuses especially on how social sustainability is understood in relation to the concepts of society and community. Furthermore, it investigates what social sustainability means, or could mean, in the specific context of water governance in South Africa – one of the most unequal countries in the world. This case study is based on original fieldwork in the country, conducted between 2017 and 2018. The theoretical exploration, together with the empirical study, demonstrate that there are two interrelated tensions between understandings of social sustainability, between approaches that place society/social cohesion in focus and those that emphasise community and between approaches that focus on basic needs and those that emphasise equal access. At stake here, between these different understandings, is the role of equity and to what extent social sustainability takes into account the situation of individuals and groups in relation to one another. Ultimately, the article raises the question of the (South African) elephant in the room: to what extent can large inequities between individuals and groups be accepted in a society considered to be (socially) sustainable?

The role of energy balance related behaviors in socioeconomic inequalities in childhood body mass index: A comparative analysis of Germany, the Netherlands, the United Kingdom, and the United States

Socioeconomic inequalities in childhood Body Mass Index (BMI) are becoming increasingly more pronounced across the world. Although countries differ in the direction and strength of these inequalities, cross-national comparative research on this topic is rare. This paper draws on harmonized longitudinal cohort data from four wealthy countries—Germany, the Netherlands, the United Kingdom (UK), and the United States (US)—to 1) map cross-country differences in the magnitude of socioeconomic inequalities in childhood BMI, and 2) to examine cross-country differences in the role of three energy-balance-related behaviors—physical activity, screen time, and breakfast consumption—in explaining these inequalities. Children were aged 5–7 at our first timepoint and were followed up at age 8–11. We used data from the German National Educational Panel Study, the Dutch Generation R study, the UK Millennium Cohort Study and the US Early Childhood Longitudinal-Kindergarten Study. All countries revealed significant inequalities in childhood BMI. The US stood out in having the largest inequalities. Overall, inequalities between children with low versus medium educated parents were smaller than those between children with high versus medium educated parents. The role of energy-balance-related behaviors in explaining inequalities in BMI was surprisingly consistent. Across countries, physical activity did not, while screen time and breakfast consumption did play a role. The only exception was that breakfast consumption did not play a role in the US. Cross-country differences emerged in the relative contribution of each behavior in explaining inequalities in BMI: Breakfast consumption was most important in the UK, screen time explained most in Germany and the US, and breakfast consumption and screen time were equally important in the Netherlands. Our findings suggest that what constitutes the most effective policy intervention differs across countries and that these should target both children from medium as well as low educated families.

The motherhood penalty in China: Magnitudes, trends, and the role of grandparenting

This paper estimates the labor market impacts of parenthood in China. We find that becoming a mother has negative impacts on women's labor outcomes. But the impacts appear to recover sooner than what has been found in other countries. A decomposition exercise suggests that parenthood plays a limited role in explaining the large gender inequality in China's labor market. We document a form of intergenerational arrangement that is prevalent among Chinese families: Upon the arrival of a child, grandmothers substantially reduce market labor supply and provide much of the childcare. Grandparents’ help with childcare likely plays an important role in alleviating the motherhood effect. Suggestive evidence indicates that in return, grandparents who help with childcare receive more intra-family transfers and report higher subjective wellbeing. We further show that the motherhood effect, though relatively small, has increased substantially over the past decades. The rising gender gap in the labor market, the declining state sector that historically provides more flexible accommodations for working mothers, and the abolishment of the one-child policy all suggest a rising burden of motherhood on labor market outcomes.

Creating a sense of urgency and provoking action – An example on the use of heat maps to address perinatal health inequalities

Health outcomes of mothers and their (unborn) children in the perinatal period, i.e., during pregnancy and shortly after birth, can vary by geographical location. This is often due to differences in exposure to medical and social risk factors. Policies aimed at reducing inequalities in perinatal health can provide significant long-term health benefits, especially for (unborn) children. However, a lack of insight into regional perinatal health inequalities means that perinatal health is not always a priority in policy formulation. Novel methods should be used to draw attention to these inequalities, spark interdisciplinary debate and encourage collaborative initiatives. In this commentary, we propose that the development of heat maps that visualize perinatal health outcomes, and risk factors for those outcomes, could be a valuable tool in doing this. Heat maps are a data visualization technique that uses color variations to emphasize value differences between areas. Visualizing health inequalities could potentially create a sense of urgency among (local) stakeholders to initiate polices aimed at improving perinatal health. We illustrate the targeted use of heat maps with an example from the city of Rotterdam, the Netherlands. Large perinatal health inequalities between neighborhoods were visualized in heat maps by a team from the Erasmus Medical Center to bring these inequalities to the attention of the municipality of Rotterdam. Local collaborative initiatives were set up to reduce perinatal health inequalities. These local initiatives formed the foundation for later national policies, including proposals to online implement heat maps regarding perinatal health topics, that are still ongoing today.

Disability-related inequalities in health and well-being are mediated by barriers to participation faced by people with disability. A causal mediation analysis

Large inequalities in health and well-being exist between people with and without disability, in part due to poor socio-economic circumstances, and potentially also related to societal factors including issues associated with accessibility and participation. To better understand the contribution of societal factors, we used a unique longitudinal survey of disability in Great Britain to quantify the extent to which barriers to participation contribute to poorer health and well-being. We used data from 2354 individuals who participated in three waves of the Life Opportunities Survey between 2009 and 2014 and compared five health and well-being outcomes (self-rated health, anxiousness, life satisfaction, life worth, happiness) between adults who acquired an impairment and those who remained disability-free. Causal mediation analysis was conducted to quantify how much of the effect of disability acquisition on each outcome was explained by barriers to participation in employment, economic life, transport, community, leisure and civic activities, social contact, and accessibility. People who recently acquired a disability had poorer health and well-being compared to people with no disability. Barriers to participation explained 15% of inequalities in self-rated health, 28% for anxiousness, 32% for life satisfaction, 37% for life worth, and 70% for happiness. A substantial proportion of the inequalities in health and well-being experienced by people with recently acquired disability were socially produced, driven by barriers to participation in different life domains. Furthermore, there was evidence that barriers to participation mediated the effect of well-being measured to a greater extent than the more clinically aligned measures, self-reported health and anxiousness. These findings highlight modifiable factors amenable to public health interventions that could lead to substantial improvements in health and well-being for people with disability.

Understanding Socio-metabolic Inequalities Using Consumption Data from Germany

ABSTRACT The Earth’s population of seven billion consume varying amounts of planetary resources with varying impacts on the environment. We combine the analytical tools offered by the socio-ecological metabolism and class theory and contribute to a novel social stratification theory to identify the differences in individual resource and energy use. This approach is applied to German society, we use per capita greenhouse gas emissions (GHG) as a proxy for resource and energy use and investigate socio-metabolic characteristics of individuals from an economic, social and cultural perspective. The results show large disparities and inequalities in emission patterns in the German society. For example, the GHG in the lowest and highest emission groups can differ by a magnitude of ten. Income, education, age, gender and regional differences (Eastern vs. Western Germany) result in distinct emission profiles. We question the focus on individual behavioral changes and consumption choices to reduce carbon emissions instead of structural changes through political decisions. We argue that emission differences are directly linked to the effects of inequalities and class differences in capitalist societies. Our research results show that natural resource and energy consumption are important for explaining social differentiation in modern societies.

Large deviation inequalities of Bayesian estimator in nonlinear regression models

Large deviation inequalities of Bayesian estimator in nonlinear regression models

Health Investments to Reduce Health Inequities in India: Do We Need More Evidence?


 
 Large inequities in health outcomes and treatment-seeking behaviour continue to exist in India, across households, states and residence. A few large populous states continue to contribute the most to multi-dimensional poverty, including indicators for health outcomes. A significant contributor is the high out-of-pocket spending that continues to be a key feature of India’s health sector, accompanied by one of the lowest levels of public investment on health. The COVID pandemic has brought out sharply the lack of preparedness of the country and its states to face a catastrophe of this kind. A resilient health sector can only be built by bridging the various gaps in key inputs into the sector – infrastructure, personnel, supplies and training. This investment is likely to bring down the demand for health services in the private sector and reduce spending on health services by households by making these affordable and accessible. A quantum jump in investment would also be required to offer health coverage that is truly universal in scope and coverage. Unless that happens, India would remain unprepared for the next calamity and continue with significant inequalities in health outcomes and access to services.

Health Impacts of the COVID-19 Lockdown Measure in a Low Socio-Economic Setting: A Cross-Sectional Study on Reunion Island.

In March 2020, the French government implemented nation-wide measures to reduce social contact and slow the progression of the emerging coronavirus responsible for COVID-19, the most significant being a complete home lockdown that lasted 8 weeks. Reunion Island is a French overseas department marked by large social inequalities. We draw the hypothesis that distancing and lockdown measures may have contributed to an increase in the social inequalities in health (SIH) on Reunion Island. The aim of our study was to describe the SIH during lockdown in the Reunionese population. We implemented a cross-sectional telephone survey conducted between 13 May and 22 July 2020, using a retrospective data collection on the lockdown period. A total of 892 adult participants (≥18 years) were recruited in the 114 large Reunionese neighborhoods using the quota method within the national "White Pages" telephone directory. Degraded psychological states, an increase in addictive behaviors, difficulties in accessing food, a decrease in physical activity, delayed medical appointments, violence against women, and health problems in children were driven by the socio-economic characteristics of the population, most often to the disadvantage of social groups exposed to poor living conditions. These results suggest that the COVID-19 lockdown contributed to an increase in SIH.

Educational inequalities in major depressive disorder over the adult life course: a microsimulation

Abstract Background Educational inequalities in major depressive disorder (MDD) pose a major challenge. Tackling this issue requires evidence on the long-term impact of intervening on modifiable factors, e.g. behavioural and psychosocial factors. Therefore, we aim to simulate the development of educational inequalities in MDD across the life course, and to assess the impact of intervening on the modifiable factors that contribute to these inequalities. Methods We used data from the prospective Dutch Lifelines Cohort Study to estimate the required input for a continuous-time microsimulation. The microsimulation allowed us to estimate the development of educational inequalities in MDD with a synthetic cohort of 500,000 individuals followed from ages 18 to 65, and to assess the potential benefit of intervening on quality of social contacts, health literacy, and smoking. Results On average, an additional 19.1% of individuals with low education will ever experience MDD between ages 18 and 65 compared to those with high education (32.0% vs 12.9%, respectively). Additionally, individuals with low education generally will develop MDD 0.9 years earlier (35.6 years vs 36.5 years, respectively) and spend 1.2 years more with MDD (6.2 years vs 5 years, respectively), than individuals with high education. Improving the quality of social contacts in individuals with low education would have the largest impact; it would reduce the inequalities in the prevalence, onset, and duration of MDD by an average of 18.4%, 18.3%, and 28.6%, respectively. Conclusions Intervening on modifiable factors, especially quality of social contacts, in individuals with low education could help reduce the large estimated educational inequalities in MDD over the life course. Key messages • There are large educational inequalities in major depressive disorder (MDD) over the life course, especially with regard to the life course prevalence of MDD. • Improving quality of social contacts, and to a lesser extent health literacy and smoking behaviours, amongst individuals with low education may help reduce the inequalities in MDD.

Gender inequalities in mortality in Lithuania: the HAPIEE Study

Abstract Introduction Gender inequalities in morbidity and mortality are important problem in countries of Central and Eastern Europe. Mortality difference between men and women in Lithuania is one of the largest in Europe. The aim of this analysis was to identify factors that influence this difference in population-based sample of middle- and older-age men and women from Lithuanian arm of the HAPIEE Study. Methods Data come from the Lithuanian part of international Health, Alcohol and Psychosocial Factors In Eastern Europe (HAPIEE) longitudinal cohort study. The analytical sample included 3729 women and 3062 men aged 45-74 years at the study baseline. The study outcomes were all-cause, CVD and cancer mortality (mean follow-up approx. 10 years). Gender difference in study outcomes, and the role of wide range of socioeconomic, demographic, behavioural, metabolic and psychosocial covariates in this association was tested by regression modelling. Results There were 913 deaths (576 in men) during the follow-up. Men had higher odds of mortality compared to women: for all-causes OR 2.42 (95% CI 2.09-2.81); for CVD 2.48 (2.03-3.08); for cancer 1.92 (1.54-2.38). BMI was identified as an effect modifier for all-cause and cancer mortality. When adjusted for confounders such as smoking, alcohol consumption or paid work, and stratified for BMI, the gender difference reduced a little for CVD mortality but remained virtually unchanged for all-cause and cancer mortality. Conclusions We found substantial and statistically significant gender inequalities in mortality in this Lithuanian study. We found that men aged 45+ years were approximately two times more likely to die than women, with CVD mortality difference being even larger. Additionally, most of gender difference in mortality remained unexplained by the main social, psychosocial, behavioural and metabolic risk factors. Key messages • Large gender inequalities in mortality have been observed in this Lithuanian study of middle- and older-age men and women. • Most of the inequalities have not been explained by available social, psychosocial, behavioural and metabolic risk factors.

Quality of facility-based maternal and newborn care around the time of childbirth during the COVID-19 pandemic

Abstract Background Multi-country studies assessing the quality of maternal and newborn care (QMNC) during the COVID19 pandemic, as defined by WHO Standards, are lacking. Methods Women who gave birth in 12 countries of the WHO European Region from March 1, 2020 - March 15, 2021 answered an online questionnaire, including 40 WHO Standard-based Quality Measures. Results 21,027 mothers were included in the analysis. Among those who experienced labour (N = 18,063), 41.8% (26.1%- 63.5%) experienced difficulties in accessing antenatal care, 62% (12.6%-99.0%) were not allowed a companion of choice, 31.1% (16.5%-56.9%) received inadequate breastfeeding support, 34.4% (5.2%-64.8%) reported that health workers were not always using protective personal equipment, and 31.8% (17.8%-53.1%) rated the health workers’ number as “insufficient”. Episiotomy was performed in 20.1% (6.1%-66.0%) of spontaneous vaginal births and fundal pressure applied in 41.2% (11.5% -100%) of instrumental vaginal births. In addition, 23.9% women felt they were not treated with dignity (12.8%-59.8%), 12.5% (7.0%-23.4%) suffered abuse, and 2.4% (0.1%-26.2%) made informal payments. Most findings were significantly worse among women with prelabour caesarean birth (N = 2,964). Multivariate analyses confirmed significant differences among countries, with Croatia, Romania, Serbia showing significantly lower QMNC Indexes and Luxemburg showing a significantly higher QMNC Index than the total sample. Younger women and those with operative births also reported significantly lower QMNC Indexes. Conclusions Mothers reports revealed large inequities in QMNC across countries of the WHO European Region. Quality improvement initiatives to reduce these inequities and promote evidence-based, patient-centred respectful care for all mothers and newborns during the COVID-19 pandemic and beyond are urgently needed. Funding: The study was financially supported by the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

ISPAD Clinical Practice Consensus Guidelines 2022: Diabetes in adolescence.

Current gaps and opportunities in screening, prevention, and treatment of cervical cancer.

In their fiscal year 2021 reports, the US House and Senate Appropriations Committees requested that the National Institutes of Health (NIH) evaluate current research related to women's health and topics that include stagnant cervical cancer survival. In response, the NIH Office of Research on Women's Health, with input from women's health experts; members of the public; representatives from NIH institutes, centers, and offices; and members of the NIH Advisory Committee on Research on Women's Health, reviewed the public health needs and current NIH activities on cervical cancer. The Advancing NIH Research on the Health of Women: A 2021 Conference held in October 2021 reviewed these findings and allowed the identification of opportunities to strengthen research. In this review, the authors summarize public health needs related to cervical cancer and NIH activities in this realm. Cervical cancer has become a rare disease in theUnited States, yet significant portions of the US population remain under screened orunscreened for cervical cancer, human papillomavirus vaccination rates remain low, access to high-quality treatment remains a challenge for many, and large inequities by race and ethnicity persist. Novel, inclusive, and intentional research isneeded to produce improvements in cervical cancer survival within the UnitedStates.

The global inequity in COVID-19 vaccination coverage among health and care workers

BackgroundHealth and care workers (HCWs) are at the forefront of COVID-19 response, at high risk of infection, and as a result they are a priority group for COVID-19 vaccination. This paper presents the global patterns in COVID-19 vaccination coverage among HCWs in 2021, how HCWs were prioritized, and identifies factors associated with the early vaccination coverage.MethodsUsing monthly data reported to the World Health Organization, the percentages of partially and fully vaccinated HCWs were computed. The rates of vaccination of HCWs for the first and second half of 2021 were compared in a stratified analysis using several factors. A multivariate analysis was used to investigate the independent associations of these factors with the percentage of HCWs fully vaccinated.ResultsBased on data from 139 Member States, as of end of 2021, 82% HCWs were reported as fully vaccinated with important variations by income groups: 33% for low income countries, 83% for lower-middle income countries, 79% for upper-middle income countries and 88% for high income countries. Overall 76% of countries did not achieve 70% vaccination coverage of their HCWs in the first half of 2021, and 38% of countries by end of 2021. Compared with the general population, the rate of HCWs full vaccination was 3.5 times higher, in particular for low income countries (RR = 5.9). Stratified analysis showed that beyond income group, the availability of vaccine doses was a critical factor of HCWs vaccination coverage with medians of 59.1% and 88.6% coverage in the first and second half of 2021, respectively for countries with enough doses to cover 70% of their population, compared with 0.8% and 47.5% coverage, respectively for countries with doses to cover 40% of their population. The multivariate analysis confirmed this observation with a 35.9% overall difference (95%CI 15.1%; 56.9%) between these two groups.ConclusionDespite being considered a priority group, more than a third of countries did not achieve 70% vaccination coverage of their HCWs at the end of 2021. Large inequities were observed with low income countries lagging behind. Additional efforts should be dedicated to ensure full protection of HCWs through vaccination.

Normalising gender equality: Changing gender norms to increase gender equality

Despite much progress over the past decades, large gender inequalities persist. In this article, I argue that we need a better understanding of social norms to understand persisting gender inequalities and to achieve further gender equality. Many social norms are gender norms: informal rules that specify what is acceptable and what is not in a group basedupongendered distinctions (e.g. female vs male). I discuss different mechanisms through which existing norms can change: the provision of information to correct misperceptions, legal reforms and policy changes, and norm transgression. I illustrate how changing norms could increase gender equality by discussing examples related to important gender norms around paid labour, caregiving, and parenthood.

Deaths of Despair: A Scoping Review on the Social Determinants of Drug Overdose, Alcohol-Related Liver Disease and Suicide.

Background: There is a lack of consensus on the social determinants of Deaths of Despair (DoD), i.e., an increase in mortality attributed to drug overdose, alcohol-related liver disease, and suicide in the United States (USA) during recent years. The objective of this study was to review the scientific literature on DoD with the purpose of identifying relevant social determinants and inequalities related to these mortality trends. Methods: Scoping review focusing on the period 2015–2022 based on PubMed search. Articles were selected according to the following inclusion criteria: published between 1 January 2000 and 31 October 2021; including empirical data; analyzed DoD including the three causes defined by Case and Deaton; analyzed at least one social determinant; written in English; and studied DoD in the USA context only. Studies were excluded if they only analyzed adolescent populations. We synthesized our findings in a narrative report specifically addressing DoD by economic conditions, occupational hazards, educational level, geographical setting, and race/ethnicity. Results: Seventeen studies were included. Overall, findings identify a progressive increase in deaths attributable to suicide, drug overdose, and alcohol-related liver disease in the USA in the last two decades. The literature concerning DoD and social determinants is relatively scarce and some determinants have been barely studied. However different, however, large inequalities have been identified in the manner in which the causes of death embedded in the concept of DoD affect different subpopulations, particularly African American, and Hispanic populations, but blue collar-whites are also significantly impacted. Low socioeconomic position and education levels and working in jobs with high insecurity, unemployment, and living in rural areas were identified as the most relevant social determinants of DoD. Conclusions: There is a need for further research on the structural and intermediate social determinants of DoD and social mechanisms. Intersectional and systemic approaches are needed to better understand and tackle DoD and related inequalities.

Influence of epidemics and pandemics on paediatric ED use: a systematic review

ObjectiveTo assess the impact of epidemics and pandemics on the utilisation of paediatric emergency care services to provide health policy advice.SettingSystematic review.DesignSearches were conducted of Medline, EMBASE, CINAHL, Scopus, Web...

Education in the Jim Crow South and Black-White inequities in allostatic load among older adults

In the U.S., Black adults consistently have higher allostatic load – an indicator of physiological dysregulation – than White adults. Education is considered a likely mechanism given racial differences in attainment, but evidence is mixed. This may be due, in part, to data limitations that have made it difficult for scholars to account for the structurally rooted systemic racism that shaped the U.S. education system and led to large racial inequities in school term length and school attendance among older adults who grew up in the Jim Crow South. Our study addresses this limitation by linking historical data on Black and White segregated school systems in the U.S. South from 1919 to 1954 to the Health and Retirement Study (HRS) to determine if a new measure of educational attainment that accounts for structural racism that led to differences in the number of school days attended by Black and White students across years and states better explains Black-White inequities in allostatic load among older adults who attended school during Jim Crow. We restrict our sample to HRS respondents racialized as White or Black, who resided in the South when they were school-aged, completed primary/secondary school between 1919 and 1954, and provided a measure of allostatic load (n = 1932). We find that our new measure of schooling – duration in school – reduced the Black-White inequity in allostatic load more so than self-reported years of schooling whether we measured allostatic load continuously (34% vs 16%) or categorically (45% vs 20%). Our findings highlight the importance of identifying and using historically informed measures of schooling that account for structurally rooted systemic racism when trying to understand how education shapes the health of individuals racialized as Black in the United States.

Intra-household food security among smallholder macadamia nuts and avocado farmers in Makhado and Thulamela municipalities, Limpopo Province, South Africa

South Africa, a middle-income country is believed to be self-sufficient in food production but there is still very large inequality and a high level of poverty experienced. Nationally, many households are food secure and yet there are a lot of compromises in an individual’s food security within households. This study analysed intra-household food security amongst smallholder tree crop farmers (macadamia nuts and avocado farmers) in the Makhado and Thulamela Municipalities of Limpopo province, South Africa. A random sample of 150 smallholder tree crop farmers was purposively selected for the study. Data was collected using a self-administered questionnaire. Analytical methods employed include descriptive statistics, Household Food Insecurity Access Scale (HFIAS), logistic regression model and Coping Strategy Use Index (CSUI). Descriptive analysis of respondents’ socioeconomic characteristics showed that most of the participants were males (54.7%) as compared to females (45.3%). About 73.3% of the farmers had formal education with an average age of 61 years. The result of HFIAS indicated that 54% were food secure, 24% were mildly food insecure, 15.3% were moderately food insecure and 6.7% were severely food insecure. The result of logistic regression on the determinants of food security revealed that educational level, off-farm work, and farming experience positively influenced intra-household food security. Coping strategies harnessed to minimize food insecurity include gathering wild fruits, relying on less expensive food, buying food on credit and a few indicating skipping meals. The study, therefore, recommends improvement in human capital development through education by relevant stakeholders and enhanced access to off-farm employment as this will economically improve respondents’ purchasing power thus resulting in reduced intra-food insecurity.