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Many children and young people (CYP) with significant mental health difficulties face barriers to accessing care from mental health services, impacting their clinical outcomes and recovery. Sociodemographic and socioeconomic factors may contribute to inequalities in access and outcomes.
Aims
To investigate the roles of sociodemographic, socioeconomic and clinical factors in influencing access to services, receipt of clinical care or diagnoses and clinical outcomes.
Method
Using data from a large, nationally representative, randomised controlled trial in England (STADIA), 1225 children aged 5–17 years and with emotional difficulties referred to child and adolescent mental health services (CAMHS) were followed up over 18 months post-referral to investigate predictors of referral acceptance, receipt of care and their clinical outcomes.
Results
Older CYP (for each 1-year increase in age, odds ratio 1.07, 95% CI: 1.02, 1.11) and those living in the least deprived neighbourhoods (deprivation index, least versus most deprived quintile: odds ratio 1.60, 95% CI: 1.05, 2.43) were more likely to have their referral accepted by CAMHS. Clinical severity (i.e. scoring above cut-off for symptoms and/or impact) was not associated with receipt of a clinical diagnosis or treatment/intervention. At 12-month post-referral, 61% met mental health ‘caseness’ criteria (v. 67% at baseline). CYP living in less deprived neighbourhoods had better clinical outcomes at 12-month follow-up (least versus most deprived quintile: odds ratio 0.49, 95% CI: 0.30, 0.81, for meeting caseness criteria, i.e. the presence of clinically significant symptoms and impairment). Females were more likely than males to have clinically significant levels of depression at 12-month follow-up (odds ratio 1.77, 95% CI: 1.28, 2.45).
Conclusions
There appear to be sociodemographic and socioeconomic inequalities in access to care and outcomes for clinically referred CYP with emotional mental health difficulties, with limited improvements in clinical outcomes 1 year following referral to CAMHS. CYP living in more deprived areas and younger children appear less likely to receive help, hampering earlier intervention efforts even in help-seeking populations.
The topic of this paper is fiscal equalization among municipalities in the four Nordic countries: Denmark, Finland, Norway, and Sweden. Fiscal equalization refers to transfers of financial resources to and between municipalities with the aim of mitigating regional differences in fiscal capacities and spending needs. More specifically, we ask the following research question: How does fiscal equalization impact spatial inequalities? We conduct a comparative empirical analysis of fiscal equalization policies in the Nordic countries. A main contribution is that we construct a granular dataset consisting of all municipalities in the four countries in 2020. We leverage this dataset to analyze inequalities before and after fiscal equalization. Our main finding is that equalization is strongest in Sweden and weakest in Norway, while Denmark and Finland are ranked in the middle.
This study assessed changes in complete pneumococcal vaccination coverage (CPVC) among Peruvian children <5 years before and after the COVID 19 pandemic and evaluated regional differences, associated sociodemographic factors and wealth-related inequality. 2018–2023 Demographic and Health Surveys (DHS) was analyzed. CPVC was defined as receiving the full 2 + 1 schedule of the 13 valent pneumococcal vaccine. Children aged 13–60 months were included. Multivariable analysis used modified Poisson regression and wealth related inequality was assessed using the Concentration index and Erreygers’s corrected Concentration index at national and regional levels. Among 95,586 children, CPVC decreased from 71.9% in 2019 to 69.4% in 2020 (p = 0.003), then returned to pre Covid levels from 2021 onward (72.2% in 2023; p = 0.001), particularly in Lima Metropolitana. Puno (53.3–58.6%) and Madre de Dios (50.9–62.1%) consistently showed the lowest coverage. Nationally, wealth- or sociodemographic related inequalities were minimal; however, regional interactions indicated that the effect of wealth on CPVC varied by area. Depending on the region, factors such as age group, household members and mather’s education were associated with lower CPVC, whereas age at first pregnancy, institutional birth, antenatal care and access to information increased CPVC. Ucayali showed persistently higher CPVC among wealthier populations. Despite a temporary decline during the pandemic, CPVC in Peru rapidly recovered, although regional gaps persist.
During the 1960s and 1970s the economic nationalism that had accompanied the growth of foreign direct investment in Latin America evolved into academic theories of dependency. This stimulated increased questioning of the role that multinationals played in the region, the introduction of policies to regulate their activities, and, at times, nationalization. This chapter examines the social consequences of foreign direct investment in resource extraction and in manufacturing. Foreign companies appeared to have gained much more from exploiting Latin American resources than local societies, which had experienced significant social and environmental harm. The balance sheet for foreign direct investment in manufacturing was more complex. It stimulated positive changes in consumption patterns and employment. However, multinationals also displaced local entrepreneurs, and they largely ignored their impact on public health and the environment. These issues remain salient in the first decades of the twenty-first century, especially with the resurgence of multinational investment in extractive activities and grassroots opposition to it.
This chapter analyzes the role of multinational enterprises in driving both globalization and deglobalization waves historically. Emerging from industrialized Western economies, multinationals played a key role in expanding global capitalism after 1840 by transferring financial, organizational, and cultural assets across borders. They took various forms and proved highly resilient, withstanding shifts in policy regimes and often reinforcing rather than disrupting institutional and societal norms that restricted growth outside the West. Their ability, and motivation, to locate value-added activities in the most attractive locations means that they have often strengthened clustering and reinforced gaps in wealth and income. The most successful non-Western economies since the 1960s – Japan, South Korea, Taiwan, and later China – limited foreign multinationals or required technology transfers to local firms. Multinationals frequently contributed to global challenges rather than solving them, yet their overall impact was a complex mix of positive and negative factors.
The Spanish agricultural sector depends on seasonal agricultural migrant workers. This study aimed to examine the associations among dietary patterns, sociodemographic factors and food security among seasonal agricultural workers.
Design:
A cross-sectional multicentre study. The dietary pattern was evaluated according to the Spanish Society of Community Nutrition recommendations for the adult population. Descriptive analysis was disaggregated according to sex. Multi-adjusted logistic models were used to assess the association between dietary patterns and explanatory variables.
Setting:
Work sites and temporary accommodations in four Spanish provinces: North Spain: Lleida and La Rioja, and South Spain: Almeria and Huelva.
Participants:
Male and Female Seasonal Agricultural Migrant Workers (n 623).
Results:
The final sample consisted of 609 migrant agricultural workers. Of these, 36 % were female, and 61 % were classified as North African. Overall, 40 % of the participants adhered to the evaluated dietary pattern. Adherence was positively associated with North African nationality, being married or cohabiting and low socio-economic status. Not skipping meals due to economic constraints and receiving food aid emerged as key factors contributing to greater adherence to the assessed dietary pattern.
Conclusions:
This study provides an initial insight into the dietary pattern of seasonal agricultural migrant workers in Spain. The findings indicate that external socio-economic and structural factors primarily shape their dietary habits. Policies aimed at enhancing food security, and other food coping strategies, such as access to food aid, are crucial for improving dietary adherence to a healthy dietary pattern.
Reducing health inequalities and improving health equity have become pressing priorities for health technology assessment (HTA) bodies and healthcare payers globally, particularly in light of the COVID-19 pandemic and its disproportionate impact on disadvantaged groups. Equity considerations are now being embedded across strategic frameworks and HTA processes in countries such as the UK, Canada, and Australia. Examples include NICE’s Core20PLUS5 initiative and PBAC’s policy shift allowing broader prescribing access to address care disparities. However, systematically incorporating quantitative equity measures into HTA presents significant challenges, given the diversity of equity subgroups and varying national contexts.
Methods
At the 2024 CDA-AMC Symposium, we convened stakeholders to discuss the challenges and opportunities for integrating equity into HTA.
Results
Key insights included ICER’s framework for embedding equity across the HTA lifecycle and NICE’s evolving application of Distributional Cost-Effectiveness Analysis (DCEA), as demonstrated in the appraisal of exagamglogene autotemcel for beta-thalassemia. DCEA, while increasingly recognized, requires robust real-world data and clearer guidance on trade-offs between equity and efficiency. Manufacturers are aligning equity goals with ESG priorities but seek greater clarity from HTA bodies on how equity evidence influences decision-making. NICE and ICER emphasize the need for deliberative processes to capture equity dimensions not reflected in traditional cost-effectiveness analysis.
Conclusion
Advancing health equity in HTA will require cross-sector collaboration to develop guidance, improve data infrastructure, and standardize methodologies. Equity-focused evidence generation across the “staircase of inequality” – from need to access and outcomes – can support more inclusive HTA and reimbursement decisions, ultimately fostering a fairer and more effective healthcare system.
The paper investigates processes and consequences of ‘philanthropic kinning’, that is the use of kinship and family idioms in constructing and maintaining personal relations between donors and recipients in philanthropy. Usual studies collapse the occurrence of kinship metaphors in philanthropy either as evidence of ‘prosociality’ (e.g. trust, care or love) or more frequently as evidence of ‘paternalism’ (power and domination of donors over recipients, and their objectification). This paper claims that introducing kinship and parenting studies into researching philanthropy would greatly refine our understanding of donor–recipient relations. In the framework of a qualitative case study of a philanthropic ‘godparenthood’ programme organised in Hungary supporting ethnic Hungarian communities in Romania, this paper looks at the roles, responsibilities and obligations various forms of philanthropic kinship offer for the participants; and relations of power unfolding in helping interactions. With such concerns, this paper complements earlier research on hybridisation of philanthropy, through its sectoral entanglements with kinship and family. Also, it contributes to research on inequalities in philanthropy, by showing how philanthropic kinning may recreate, modify or reshape donor–recipient power relations in diverse ways.
This lecture addresses the political impact of the Great Recession in a context of rising inequalities and retrenching welfare states. Do hard times fuel apathy or revolt, abstention or support for the extremes, and more particularly, in the European context, for thriving radical rights? To answer these questions, I shall take the case of France, in the 2012 presidential election, the first post-crisis one. I shall focus on the poor, the disadvantaged: those hardest hit by the recession.
The concept of precarity is increasingly being applied in social gerontology to understand risks and uncertainties faced by older adults. However, existing research has not captured precarity quantitatively nor has it modelled its effect on older adults’ health. We therefore develop a Later Life Precarity Index and model its association with frailty. Using longitudinal data on 15,733 older adults from the English Longitudinal Study of Ageing, we examine the association between frailty and risks across the domains of finances, pensions, employment, housing, relationship and unpaid care-giving. We then develop the Later Life Precarity Index and model its longitudinal association with a Frailty Index using hybrid panel regression. The results indicate that multiple social risks are strongly and independently associated with frailty, particularly around finances, housing, fuel poverty and food insecurity. In longitudinal models, the precarity index explains both between-individual differences and within-individual changes in frailty and performs substantially better than standard measures of socio-economic status (wealth and education). The strong longitudinal association of the precarity index with frailty suggests that social gerontology’s growing focus on precarity is a useful lens for understanding the diverse, changing and new forms of social risk that impact frailty. By developing, testing and sharing this novel measure of later life precarity, this study brings potential for new understandings of the evolving drivers of inequalities in the health of older adults.
Despite volunteering being a feature of community life in the UK, differences as to who volunteers are evident. Reporting on a rapid review of the evidence on volunteering and inequalities, the aim of this paper is to provide an overview of the breadth and interconnectedness of barriers to volunteering for potentially disadvantaged groups. Sixty-seven articles were identified, to produce a map of factors affecting volunteer participation. Findings suggest that whilst different demographic groups experience specific barriers to volunteering, there are areas of commonality. Analysis shifts the onus of volunteering away from the level of individual choice (a dominant emphasis in policy and practical discussions around promoting volunteering) and towards the influence of structural factors related to broader exclusionary processes. Those who potentially have the most to gain from volunteering are the least likely to participate. Whilst the benefits of volunteering are increasingly documented by research and championed by policy, there are questions about the success of this approach given that the underlying social inequalities present substantive barriers to volunteering and must be addressed to promote greater access.
The chapter discusses the only partial coming to terms with the genocide trauma against the background of the socio-economic-political and cultural-religious conditions of this Southeast Asian country. The surviving victims and their descendants suffered severe marginalization in their role: their fates were not really dealt with publicly, and they were not granted the status of historical victors. The psychosocial and social science research conducted in relation to genocide survivors, generally from the late 1990s and largely only in the 2000s and 2010s, mirrored in many respects the international developments. It was mainly researchers from the Global North who published studies on the post-genocidal situation in Cambodia. However, anthropologists from the Global North dealt extensively with certain cultural Cambodian aspects of the genocide aftermath. One cultural syndrome garnered particular attention: baksbat, which is characterized by a subjective feeling of ‘broken courage’. This phenomenon manifests as both a normal reaction and a pathological, exaggerated reaction. The treatment approaches for survivors usually include Buddhist or ethnically mediated rituals as an amalgam alongside internationally developed testimony therapy.
Vegetable consumption in many countries is less than recommended and even lower in low-income households. This study explored the determinants of current vegetable food choice in households with limited food budgets to inform the implementation of a national vegetable promotion programme. Five focus groups and one individual interview were conducted with twenty-nine parents who self-identified as ‘shopping on a budget’ in an area of multiple deprivation in the southeast of England. Transcripts of audio recordings were coded in NVivo and analysed using inductive thematic analysis. Four main themes which shaped the range of vegetables brought into the home were identified: (1) attributes of vegetables, (2) attributes of parents including their vegetable norms, knowledge and skills (veg-literacy), and interest and opportunity to invest time and effort in vegetables, (3) family food dynamics, and (4) influence of retailers. Overarching this was parents’ capacity to absorb the risk of wasting food, money, time, and effort on vegetables and damaging trust in the parent–child food relationship. The data suggest there is a common set of ‘core vegetables’, which are routinely bought. When money is tight, parents only buy vegetables they know their children will eat and are generally not persuaded to buy ‘off-list’ in response to price discounts or promotions. Cost is not always the main barrier to increased vegetable purchase. To avoid unintentionally widening dietary inequalities, supply-side interventions to promote vegetable consumption need to be designed alongside targeted actions that enhance the capacity of low-income households to respond.
The United States, despite its generally favorable rankings on international indices, has significant corruption problems. Those issues cannot be ignored, but neither should they be exaggerated or oversimplified. American corruption is not any one single problem: contrasts are apparent among the states, across regions, and at different levels of the federal system. Some are illegal, but other types are legal – or not clearly against the law. While corruption is a significant issue in the context of law enforcement, race relations, environmental policy, and public health, its sources, consequences, and context differ from one sector to the next. Inequalities along racial and class lines add further complexities and significantly affect the prospects of reform. Checking corruption and dealing with its consequences will be a matter not only of enacting and enforcing sound laws but of how well we govern ourselves within a large, complicated, multi-level, but fundamentally democratic constitutional framework.
The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
Aims:
This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
Methods:
Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
Findings:
The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF’s introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
Cyclones, flash floods, droughts, and pollution batter the aspirations of people living at the sharp end of water insecurity. By charting the daily water use behaviour of people in Kenya and Bangladesh for a year, this book explores the intersecting drivers of global water risks and the spatial and seasonal inequalities. Comprising a clear methodological chapter and four detailed case studies of both urban and rural areas, it critically reviews existing policy and institutional design, arguing for a new architecture in allocating risks and responsibilities fairly and effectively between government, communities, enterprises, and water users. In identifying the risks and potential responses for policy and investment action, it provides theoretical insights and a practical guide to developing more effective policy in Kenya and Bangladesh, with solutions that will be applicable in other regions facing similar challenges. This title is also available as Open Access on Cambridge Core.
In the field of American state politics, the tension between majoritarian institutions and equality has largely been ignored. Do state institutions that empower majority preferences exacerbate disparities in social outcomes? Under what conditions do majoritarian institutions exacerbate inequalities in the American states? Our argument is that equality is most likely to be threatened under majoritarian institutions when (1) there are systemic participatory biases and/or (2) there are widespread prejudices about particular groups in society. We find that more majoritarian institutions are associated with larger disparities between White and Black life expectancy and poverty rates across the American states, but not differences in educational attainment. We also find that this effect is moderated by racial context, with majoritarian institutions being associated with greater disparities for states with diverse racial contexts and smaller disparities in more homogenous states. These findings suggest that majoritarian institutions operate to the benefit of the White majority, while coming at the cost of minority population outcomes when a racial threat is perceived, and presumably, public opinion is biased.
Nozick’s ‘utility monster’ is often regarded as impossible, because one life cannot be better than a large number of other lives. Against that view, I propose a purely marginalist account of utility monster defining the monster by a higher sensitivity of well-being to resources (instead of a larger total well-being), and I introduce the concept of collective utility monster to account for resource predation by a group. Since longevity strengthens the sensitivity of well-being to resources, large groups of long-lived persons may, if their longevity advantage is sufficiently strong, fall under the concept of collective utility monster, against moral intuition.
Social prescribing is growing rapidly globally as a way to tackle social determinants of health. However, whom it is reaching and how effectively it is being implemented remains unclear.
Aims
To gain a comprehensive picture of social prescribing in the UK, from referral routes, reasons, to contacts with link workers and prescribed interventions.
Method
This study undertook the first analyses of a large database of administrative data from over 160 000 individuals referred to social prescribing across the UK. Data were analysed using descriptive analyses and regression modelling, including logistic regression for binary outcomes and negative binomial regression for count variables.
Results
Mental health was the most common referral reason and mental health interventions were the most common interventions prescribed. Between 72% and 85% of social prescribing referrals were from medical routes (primary or secondary healthcare). Although these referrals demonstrated equality in reaching across sociodemographic groups, individuals from more deprived areas, younger adults, men, and ethnic minority groups were reached more equitably via non-medical routes (e.g. self-referral, school, charity). Despite 90% of referrals leading to contact with a link worker, only 38% resulted in any intervention being received. A shortage of provision of community activities – especially ones relevant to mental health, practical support and social relationships – was evident. There was also substantial heterogeneity in how social prescribing is implemented across UK nations.
Conclusions
Mental health is the leading reason for social prescribing referrals, demonstrating its relevance to psychiatrists. But there are inequalities in referrals. Non-medical referral routes could play an important role in addressing inequality in accessing social prescribing and therefore should be prioritised. Additionally, more financial and infrastructural resource and strategic planning are needed to address low intervention rates. Further investment into large-scale data platforms and staff training are needed to continue monitoring the development and distribution of social prescribing.
Reducing inequalities in preconception health and care is critical to improving the health and life chances of current and future generations. A hybrid workshop was held at the 2023 UK Preconception Early and Mid-Career Researchers (EMCR) Network conference to co-develop recommendations on ways to address inequalities in preconception health and care. The workshop engaged multi-disciplinary professionals across diverse career stages and people with lived experience (total n = 69). Interactive discussions explored barriers to achieving optimal preconception health, driving influences of inequalities and recommendations. The Socio-Ecological Model framed the identified themes, with recommendations structured at interpersonal (e.g. community engagement), institutional (e.g. integration of preconception care within existing services) and environmental/societal levels (e.g. education in schools). The co-developed recommendations provide a framework for addressing inequalities in preconception health, emphasising the importance of a whole-systems approach. Further research and evidence-based interventions are now needed to advance the advocacy and implementation of our recommendations.