Socioeconomic Inequalities Research Articles

Latina Women’s Perinatal Experiences and Perspectives Around Discrimination, Anti-immigrant Policies, and Community Violence

ObjectiveTo describe experiences of Latina women who were currently pregnant or recently gave birth around discrimination, anti-immigrant policies, and community violence during the early COVID-19 pandemic. DesignQualitative secondary analysis. SettingOnline or phone interviews. ParticipantsLatina women who were currently pregnant or recently gave birth (N = 26). MethodsWe used reflexive thematic analysis to examine transcribed data from semistructured interviews conducted during the early COVID-19 pandemic with a subgroup of participants enrolled in a larger study related to prenatal care. Participants were English- or Spanish-speaking, Medicaid-eligible, Latina-identifying women who resided in Fresno County, California. We analyzed responses to questions about personal discrimination, the Black Lives Matter movement, and immigration policies using the theoretical frameworks of critical race theory and the political economy of health. ResultsWe identified four major themes: Avoidance of Community Engagement, Chronic Fear and Vigilance, The Role of Media, and Everyday Discrimination and Injustice. ConclusionParticipant experiences reflect the pervasiveness of fear and socioeconomic inequity and call attention to the racialized structures that affect health and health care access for Latina women. These exposures during the perinatal period may have intergenerational effects. These findings underscore the need for responsive and race-conscious perinatal nursing care for Latina women, assessment of the effect of the current sociopolitical environment on well-being, and policies that support equitable access to health and social care.

Socioeconomic inequalities, genetic susceptibility, and risks of depression and anxiety: A large-observational study

ObjectivesThis study aimed to investigate the interplay between genetic susceptibility and socioeconomic disparities on psychiatric disorders. MethodsIn this study, we utilized data from the UK Biobank to analyze the Generalized Anxiety Disorder (GAD)-7 scale (N = 74,425) and the Patient Health Questionnaire (PHQ)-9 (N = 74,101), along with the Index of Multiple Deprivation (IMD). The polygenic risk score (PRS) was calculated to assess the genetic risk associated with GAD-7/PHQ-9 scores, and the individuals were classified into low, medium, and high genetic risk groups according to tertiles of PRSs related to the GAD-7/PHQ-9. Linear regression models were used to explore the relationships between GAD-7/PHQ-9 scores and IMD scores in patients with different genetic susceptibilities. ResultsDisadvantaged socioeconomic status was associated with the risk of anxiety and depression across all strata of genetic risk, and stronger associations were shown for individuals with greater genetic susceptibility. From low to high genetic risk, the risk of psychiatric disorders increased for the GAD-7 (β = 0.002 to 0.032) and PHQ-9 (β = 0.003 to 0.045) scores. In addition, strong associations of high genetic risk with anxiety (β = 0.875) and depression (β = 1.152) were detected in the IMD quartile 4 group compared with the least deprivation quartile group. Furthermore, income and employment were estimated to contribute strongly to anxiety (βemployment = 7.331, βincome = 4.492) and depression (βemployment = 9.951, βincome = 6.453) in the high genetic risk group. ConclusionThe results suggest that we should pay more attention to psychiatric disorders with high genetic susceptibility and try to improve their socioeconomic status to prevent the development of psychiatric disorders.

Addressing Hypertension Disparities via Systems Dynamics: Insights From Community Health Connections.

Background and objective Hypertension remains a major public health challenge in the United States, disproportionately affecting various demographic groups. Significant disparities persist in hypertension prevalence and control due to interactions between socioeconomic factors, healthcare access, and systemic inequities. In this study, we aimed todetermine the impact of socioeconomic and healthcare factors on hypertension control among patients at Community Health Connections (CHC), a Federally Qualified Health Center serving 36 communities in North Central Massachusetts, and identify effective interventions using systems dynamics modeling to promote health equity. Materials and methods This was a retrospective observational study using data from 2023 CHC patients, and the National Health and Nutrition Examination Survey (NHANES) 2011-2014. Systems dynamics modeling was employed to visualize interactions among factors influencing hypertension outcomes. The study included 4,870 CHC patients. Participants were selected based on clinical records and comprised 3,690 White participants (76%), 464 Black/African American participants (10%), 108 Asian participants (2%), and 608 classified as Other/Non-reported (12%). The cohort included 2,490 males (51%) and 2,380 females (49%). Socioeconomic factors (e.g., race, age, insurance status) and healthcare access were the study variables. The primary outcome was hypertension control, defined as a blood pressure reading of <140/90 mmHg. The study measured control rates across different demographic groups and assessed the impact of socioeconomic and healthcare factors on these rates. Results Among the 4,870 CHC patients, 3,007 (62%) achieved hypertension control. The overall hypertension control rate varied significantly by race: White: 68.6%, Black/African American: 61.6%, Asian: 63.2%, and Other/Non-reported: 65.6%. Insured patients had a control rate of 67.7%, compared to 37.5% for uninsured patients (p<0.001). Systems dynamics models illustrated how socioeconomic disparities and healthcare access issues amplify health inequities. Key interventions identified include, but are not limited to, multidisciplinary care teams, community health worker programs, and telehealth services. Conclusions Addressing hypertension disparities among CHC patients requires a systemic approach integrating socioeconomic, healthcare, and policy-related interventions. Systems dynamics modeling provides a framework for designing and implementing targeted interventions, enhancing health equity, and improving hypertension control outcomes in underserved populations. Further research is needed to test the effectiveness of these interventions before their broad implementation.

Abstract P114: Reducing Racial Disparities in Hypertension Control using Multicomponent, Equity-Centered Approach

Background: Black Americans have the highest prevalence of hypertension among all racial or ethnic groups in the United States and are five times more likely to die from hypertension compared to non-Hispanic whites. Perceived discrimination in healthcare, clinician and institutional bias, and socioeconomic and environmental inequities contribute to uncontrolled hypertension in this population. Multilevel, multicomponent interventions have effectively improved blood pressure control among Black Americans but remain inadequately implemented in the clinical setting. An integrated nursing/public health quality improvement study was designed to address this gap between evidence and integration into clinical practice. Methods: Using a one group pre/posttest design, we examined the effect of a 12-week intervention on blood pressure among Black Americans with uncontrolled hypertension aged 18 and older in the primary care setting. Intervention components included remote blood pressure monitoring, weekly phone coaching with culturally congruent care, medication intensification, and a standardized hypertension protocol. Results: The average age of the participants (n=35) was 64 years, and two thirds (n=23) were female (66%). The mean difference in both systolic and diastolic blood pressure decreased significantly (23 mmHg and 11mmHg, t-test –9.736 and –5.502, p-value &lt;.001). At 12 weeks, 87% of participants had achieved blood pressure control. The intervention also significantly improved medication adherence and hypertension knowledge (p-value &lt;.001). Conclusion: A multicomponent, culturally congruent quality improvement intervention significantly improved blood pressure among Black Americans. Implications: Scaled up implementation of multicomponent, equity-centered, culturally congruent approaches are needed to reduce racial disparities in hypertension control.

Association between social engagement frequency and depression among the older people in China: evidence from the 2011–2018 China Health and Retirement Longitudinal Study

BackgroundDepression in older people is a major concern in China. Despite being known as a protective factor, it is unclear the extent to which social engagement mitigates depression or mediates...

Parental Postpartum Depression and Children’s Socioemotional Development: The Role of Socioeconomic Inequality

Parental Postpartum Depression and Children’s Socioemotional Development: The Role of Socioeconomic Inequality

Academic Essay On Equitable Access To Mental Health Services In Brazil

Equitable access to mental health services in Brazil faces complex and interconnected challenges. Among the main issues are regional inequalities, socioeconomic barriers, and the stigma associated with mental disorders. Regional inequality results in significant differences in the quality and availability of mental health services between urban and rural areas. While large cities such as São Paulo and Rio de Janeiro have advanced infrastructure and qualified professionals, rural areas and urban outskirts suffer from a lack of resources and professionals, limiting access to necessary care. Socioeconomic barriers also play a crucial role. Low-income populations face additional difficulties, such as lack of transportation and inadequate health insurance, which restrict access to mental health services. The lack of information and the stigmatization of mental disorders worsen the situation, discouraging individuals from seeking treatment due to fear of discrimination and prejudice. To address these challenges, it is essential to adopt integrated strategies. Expanding mental health infrastructure in underserved areas and creating integrated care networks are fundamental. Public policies should reduce socioeconomic inequalities by providing financial support and improving transportation. Awareness campaigns about mental health can overcome informational barriers and stigma. Continuous training of health professionals and community participation are also crucial to ensure inclusive and locally adapted care. With a coordinated effort, it is possible to promote more just and comprehensive access to mental health services in Brazil.

Hospital volume does not mitigate the impact of area socioeconomic deprivation on heart transplantation outcomes.

While structural socioeconomic inequity has been linked with inferior health outcomes, some have postulated reduced access to high-quality care to be the mediator. We assessed whether treatment at high-volume centers(HVC) would mitigate the adverse impact of area deprivation on heart transplantation(HT) outcomes. All HT recipients ≥18years were identified in the 2005-2022 Organ Procurement and Transplantation Network. Neighborhood socioeconomic deprivation was assessed using the previously validated Area Deprivation Index. Recipients with scores in the highest quintile were considered Most Deprived (others: Less Deprived). Hospitals in the highest quartile by cumulative center volume (≥21 transplants/year) were classified as HVC. The primary outcome was post-transplant survival. Of 38,022 HT recipients, 7,579 (20%) were considered Most Deprived. Following risk adjustment, Most Deprived demonstrated inferior survival at 3(hazard ratio[HR] 1.14, 95%confidence interval[CI] 1.06-1.21) and 5 years following transplantation (HR 1.13, CI 1.07-1.20). Similarly, Most Deprived faced greater graft failure at 3(HR 1.14, CI 1.06-1.22) and 5 years (HR 1.13, CI 1.07-1.20). Evaluating patients transplanted at HVC, Most Deprived continued to face greater mortality at 3(HR 1.10, CI 1.01-1.21) and 5 years (HR 1.10, CI 1.01-1.19). The interaction between Most Deprived status and care at HVC was not significant, such that transplantation at HVC did not ameliorate the survival disparity between Most and Less Deprived. Area socioeconomic disadvantage is independently associated with inferior survival. Transplantation at HVC did not eliminate this inequity. Future efforts are needed to increase engagement with longitudinal follow-up care and address systemic root causes to improve outcomes.

Associations between socioeconomic factors and PSA testing in a population-based organised testing programme and routine healthcare: a register-based study of 50-year-old men

ObjectivePopulation-based, organised prostate cancer testing (OPT) programmes were started in Sweden in 2020. The influence of socioeconomic factors on prostate cancer testing in this setting is not known. We examined...

Higher education and the transition to adulthood: socioeconomic inequality in college students’ self-narratives

AbstractHow does socioeconomic status relate to the self-narratives youth craft in higher education? This article examines in-depth interviews with 96 students at a broad-access public university to illuminate how narratives of the transition to adulthood are shaped by socioeconomic inequality among youth who enroll in the same postsecondary institution. Although most students across backgrounds agreed that they were “not yet adults,” there were differences in the ways they described their paths to adulthood. Less socioeconomically advantaged students characterized their journeys as stalled, focusing on difficulties obtaining traditional markers of adulthood. These participants struggled to incorporate college experiences into their narratives and engaged in self-deprecation and self-blame. Meanwhile, more socioeconomically advantaged students highlighted personal growth in college to portray themselves as individuals with potential, who were positioned for future success. These findings provide unique insight into higher education’s role in cultural reproduction and have implications for students’ opportunities transitioning to postbaccalaureate life.

Socioeconomic Inequities in Pap Test Use Among Black Women in the United States: An Intersectional Approach.

Research investigating racialized inequities in cervical cancer screening has rarely considered the influence of socioeconomic position (SEP), a key social determinant of health that intersects with race/ethnicity and racism. Thus, data on socioeconomic inequities in Pap test use within racialized groups-including Black women, who are at elevated risk of cervical cancer morbidity and mortality-are limited. Using 2011-2019 data from the National Survey of Family Growth and guided by an intersectional framework, we used multivariable logistic regression to examine the association between educational attainment, employment status, and income and the adjusted odds of Pap test use in the last 3years among Black U.S. women. Compared to Black women with a bachelor's degree or greater, those with less than a high school diploma ([odds ratio] = 0.45; [95% confidence interval] 0.31-0.67) and a high school diploma/GED (0.57; 0.40-0.81) had significantly lower odds of Pap test use, adjusting for sociodemographic factors. Unemployed women had significantly lower adjusted odds of Pap test use compared to employed women (0.67; 0.50-0.89), and women living below 100% of the federal poverty level (FPL) had significantly lower adjusted odds of Pap test use relative to those living at or above 300% FPL (0.63; 0.45-0.88). Low-SEP Black women had significantly lower adjusted odds of Pap test use relative to their higher SEP counterparts. Interventions that address both racism and economic barriers to care are needed to facilitate access to regular cervical cancer screening among low-SEP Black women.

Nutrition for all? Input subsidies and equitable diets

AbstractWhile agricultural input subsidies can improve productivity and nutrition, a key unanswered question is whether such government initiatives influence equitable nutrition access across genders. We study gender disparities in dietary diversity among 7783 smallholder farms in Zambia, evaluating the potential of subsidies to mitigate gaps. Using Oaxaca‐Blinder decomposition methods, results reveal female‐headed households (FHHs) have significantly lower dietary diversity than male‐headed ones, with gaps ranging from 6% to 12% along the distribution. Male‐headed households (MHHs) also show 9% higher input subsidy participation, influenced by education and agricultural extension access among others. Crucially, increased FHHs' participation in input subsidies could potentially close the gendered dietary diversity gap, even surpassing MHHs by 17.8%, underscoring the promise of targeted efforts to improve gender equity. However, achieving socioeconomic parity with MHHs further amplifies positive impacts. Given these findings, facilitating FHHSs' access to input subsidies can promote more equitable nutrition outcomes between genders. Broader participation could be enabled by strengthening agricultural extension and education to equip farmers, especially marginalized female‐headed and remote households, to leverage subsidized inputs. Overall, this study demonstrates that prioritizing female‐headed households' inclusion in input subsidy programs, alongside integrated support, holds strong potential to narrow gendered disparities in dietary diversity among smallholder farms in Zambia. It provides key insights to inform the design of nutrition‐sensitive, gender‐aware agricultural policies.

“The ones at the bottom of the food chain”: structural drivers of unintended pregnancy and unsafe abortion amongst adolescent girls in Zambia

BackgroundAccess to safe abortion care is highly unequal and fundamentally rooted in socioeconomic inequalities which are amplified by restrictive social norms and legal systems. We analyse these inequalities along the reproductive health continuum amongst adolescent girls in Zambia.MethodologyThis paper draws from 20 focus group discussions conducted in 2021 with community members (young/adult) in five urban, peri urban, and rural sites in Zambia. Data was analysed using thematic analysis.ResultsAdolescent pregnancy in the community was reported to be very common across the communities with girls from poorer families being disproportionately affected. Parents were reported to be complicit in facilitating their daughter’s sexual-economic exchanges which emerged as a key driver of pregnancies. Young age and unmarried status meant adolescent girls could face triple stigma: stigma around accessing contraception to prevent a pregnancy, stigma in experiencing an unintended pregnancy and stigma around terminating an unintended pregnancy. There were clear socioeconomic differences in adolescent girl’s exposure to community and health provider censure and/or acceptance of their pregnancy, and in their ability to conceal an abortion. Having the means to pay for health care allows some adolescents to seek terminations earlier and to access private health facilities while poorer adolescent girls face greater exposure to community censure through their embeddedness within the community. Abortions in this group attracts greater visibility through complications arising from their constrained choice for safe abortion methods. Stigmatising attitudes of community members also undermined adolescents’ reproductive agency and mental health. For adolescents who choose to keep an unintended pregnancy, reintegration into school was highly challenging despite a national policy in place, with marriage being viewed as the only future option for poorer teenage mothers.ConclusionThe embeddedness of adolescent pregnancies within community structures of economic insecurity and gendered and age-related power relations highlight the importance of introducing community level approaches to tackle unintended pregnancies and unsafe abortion. Understanding teenage pregnancy as a community issue creates opportunities for community level support to young girls especially when they return to school.

Brain clocks capture diversity and disparities in aging and dementia across geographically diverse populations.

Brain clocks, which quantify discrepancies between brain age and chronological age, hold promise for understanding brain health and disease. However, the impact of diversity (including geographical, socioeconomic, sociodemographic, sex and neurodegeneration) on the brain-age gap is unknown. We analyzed datasets from 5,306 participants across 15 countries (7 Latin American and Caribbean countries (LAC) and 8 non-LAC countries). Based on higher-order interactions, we developed a brain-age gap deep learning architecture for functional magnetic resonance imaging (2,953) and electroencephalography (2,353). The datasets comprised healthy controls and individuals with mild cognitive impairment, Alzheimer disease and behavioral variant frontotemporal dementia. LAC models evidenced older brain ages (functional magnetic resonance imaging: mean directional error = 5.60, root mean square error (r.m.s.e.) = 11.91; electroencephalography: mean directional error = 5.34, r.m.s.e. = 9.82) associated with frontoposterior networks compared with non-LAC models. Structural socioeconomic inequality, pollution and health disparities were influential predictors of increased brain-age gaps, especially in LAC (R² = 0.37, F² = 0.59, r.m.s.e. = 6.9). An ascending brain-age gap from healthy controls to mild cognitive impairment to Alzheimer disease was found. In LAC, we observed larger brain-age gaps in females in control and Alzheimer disease groups compared with the respective males. The results were not explained by variations in signal quality, demographics or acquisition methods. These findings provide a quantitative framework capturing the diversity of accelerated brain aging.

The Privilege of Well-Being in an Increasingly Unequal Society

This article provides an overview of a model of psychological well-being put forth over 30 years ago. The intent was to advance new dimensions of positive functioning based on integration of clinical, developmental, existential, and humanistic thinking along with Aristotle’s writings about eudaimonia. The operationalization and validation of the model are briefly described, followed by an overview of scientific findings organized around (a) demographic and experiential predictors of well-being, (b) well-being as predictors of health and biomedical outcomes, (c) pathway studies that examine intervening processes (moderators, mediators), and (d) underlying mechanistic processes (neuroscience, genomics). Much prior work underscores the benefits of well-being, including for longevity. Widening socioeconomic inequality is, however, increasingly compromising the well-being of disadvantaged segments of the population. These problems have been exacerbated by recent historical stressors (Great Recession, COVID-19 pandemic). Cumulative hardships from these events and their implications for health are critical targets for future science and practice.

Diverging destinies: How children are faring under demographic transition

India reached the replacement level of fertility in 2020. However, the journey of fertility transition is unconventional and heterogeneous within the country and across the different socio-economic groups. The fertility transition is considered to be faster than its socio-economic and health transition in several states. Thus, it has been presumed that the returns to fertility decline are heterogeneous across the states and population sub-groups. Our specific hypothesis is that although rich and poor, and educated and un-educated, everyone had significantly contributed to the fertility decline in response to family planning policies, only those socio-economically better-off have been investing relatively more in their children compared to the poor, and this has led to diverging destinies for children. We tested this supposition using a macro-level panel dataset (1992–2021), fixed and random effects, and IV regression models. The results confirm that child health care and outcomes have diverged while fertility declined from 1992 to 2021. These results are sustained in multiple robustness checks. While fertility is declining with highly state-sponsored family planning programmes, the persistent socio-economic inequalities are leading to unequal progress in health outcomes for children in India.

Economic Inequality, Life Expectancy, and Interpersonal Violence in London Neighborhoods.

Positive associations between levels of socioeconomic inequality and homicide rates have been reported at various geographical levels (e.g., between countries, states, cities, and neighborhoods within a city). However, the extent to which inequality predicts levels of non-lethal violence has been less frequently studied. The present study was conducted to investigate the association between socioeconomic inequality and levels of non-lethal interpersonal violence across neighborhoods of London during the period 2010 to 2012, using two independent data sources: Metropolitan Police service recorded violent crime and London Ambulance Service recorded assaults. Mean income per person and local life expectancy were included as additional predictors. Following exclusions due to census boundary changes, across 533 London wards, there were positive bivariate associations between both violence measures and a measure of inequality between neighborhoods (census lower layer super output areas [LSOAs]) within a ward. Moreover, there were negative bivariate associations between violence rates and both ward mean income and life expectancy measures for males and females. However, in a regression analysis only inequality and male life expectancy were consistent predictors of rates of interpersonal violence across outcome measures. The results of the present study provide further evidence of an association between levels of economic inequality and rates of interpersonal violence. The findings, for variation in rates of non-lethal violence across small geographical areas (neighborhoods), build on previous research that has mostly focused on rates of lethal violence and has tended to use aggregate measures across larger geographical areas.

Imagining Just and Sustainable Food Futures: Using Interactive Visualizations to Explore the Possible Land Uses and Food Systems Approaches in Revelstoke, Canada

Food systems are linked to multiple critical sustainability issues such as climate change, environmental degradation, and growing socioeconomic inequalities, and there is a clear need for transformative changes in how food systems are imagined and enacted. For transformations to occur, local governments and stakeholders must be able to consider achievable and desirable futures that involve radically different reconfigurations of space and land use. Based in Revelstoke, Canada, this study uses interactive visualization methods to engage local government and food systems stakeholders in an exploration of three future food systems scenarios that center on changes in food supply, food affordability, and food governance. An interactive visualization tool was developed using the Unity3D game engine, which visualizes how transformations of an underutilized railway site in Revelstoke may appear in 2100. The visualizations were presented to the study participants (n = 10) through an online, Zoom-based workshop, where ‘walkthroughs’ of the scenarios were performed by the researchers and the participants subsequently provided feedback. The results of this study indicate that visualization tools can elicit emotional responses, convey human relationships with food and nature, communicate power dynamics, and incorporate social justice considerations. The results also show that the visualization’s representation of local infrastructure and services, the completeness of a virtual environment, and the plausibility of a depicted future affect the user assessment of the visualized scenarios.

Urban sustainability in social housing environments: A spatial impact assessment in Bogotá, Colombia

As cities adapt to the challenges of rapid urbanization, sustainable development goals, and post-pandemic realities, understanding the intricacies of urban sustainability is vital. This study presents a spatial impact assessment of urban sustainability, focusing on the distinctive requirements of social housing urban environments in Bogota, Colombia. By contextualizing this study in the ever-evolving post-pandemic paradigm, it depicts the current conditions of the city towards future development scenarios. The sustainability assessment relies on a set of 11 Key Performance Indicators (KPIs), emphasizing the particular needs of social housing and offering a comprehensive analysis that links the conditions of the urban environment, environmental quality, and social well-being, all under the umbrella of Sustainable Development Goal 11. Specific spatial analysis using GIS tools (e.g. spatial interpolation, network analysis, multispectral imagery analysis), statistical analysis, and data engineering were employed to evaluate the selected KPIs. This evaluation revealed distinct spatial patterns of socioeconomic inequity, primarily impacting areas with a higher concentration of social housing within the city. These findings highlight critical areas requiring strategic attention to promote the city's sustainability transition. Key insights indicate that areas lacking sufficient access to green spaces and essential urban services, alongside higher pollution levels, are associated with lower social well-being, reduced perceptions of security, and are characterized by high population density and a significant presence of social housing. These results, available on an interactive web-GIS app, underscore the imperative for policies and planning that not only address the provision of social housing but also ensure a sustainable built environment, shaping a sustainable, inclusive, safe, and resilient future. The methodology and insights presented in this study are also applicable and scalable to similar urban contexts globally.

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data

BackgroundThe Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform’s impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities.MethodsThis register-based study used a multiple-group interrupted time-series design for the study period 2001–2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18–85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII).ResultsAll three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)).ConclusionsThe study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.