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BackgroundDue to stigma and discrimination, gay, bisexual and other men who have sex with men (gbMSM) potentially carry a heightened burden of loneliness. This analysis investigates loneliness among gbMSM and its relationship with self-rated physical health, along with the mediating effect of depression.MethodsParticipants were recruited using respondent-driven sampling into the Momentum Health Study (February 2012–February 2015) with follow-up visits occurring every 6 months until February 2018. Using computer-assisted self-interviews, measures of loneliness were assessed using a 6-item Loneliness Scale for Emotional and Social Loneliness (lonely vs not lonely). Current physical health was self-assessed (poor, fair, good, very good or excellent). A multivariable generalised linear-mixed model with a logit link function was used to examine the relationship between loneliness and self-rated physical health. We further investigated the mediating effect of depressive symptomatology on this relationship via the Hospital Anxiety and Depression Scale.ResultsOf the 770 participants included, we found that 61% (n=471) experienced loneliness at baseline. Of the 674 (88%) who reported good/very good/excellent physical health, 59% (n=391) reported loneliness, compared with 87% (n=80) of those in poor/fair self-rated physical health. After adjustment for confounding, loneliness was associated with poor self-rated physical health (adjusted OR 1.71; 95% CI 1.13 to 2.60). Depressive symptomatology was found to partially mediate this relationship.ConclusionThere may be a need for the integration of social, mental and physical health programming, targeted towards gbMSM, to alleviate the degree of loneliness experienced and its co-occurrence with poor self-rated physical health.

BackgroundOver the past several decades, governments have enacted far-reaching reforms aimed at reducing the generosity and coverage of welfare benefits. Prior literature suggests that these policy measures may have deleterious effects on the health of populations. In this study, we evaluate the impact of one of the largest welfare reforms in recent history—the 2005 Hartz IV reform in Germany—with a focus on estimating its effect on the health of the unemployed.MethodsWe employed a quasi-experimental difference-in-differences (DID) design using population-based data from the German Socio-Economic Panel Study, covering the period between 1994 and 2016. We applied DID linear probability modelling to examine the association between the Hartz IV reform and poor self-rated health, adjusting for a range of demographic and socioeconomic confounders.ResultsThe Hartz IV reform was associated with a 3.6 (95% CI 0.9 to 6.2) percentage point increase in the prevalence of poor self-rated health among unemployed persons affected by the reform relative to similar but unaffected controls. This negative association appeared immediately following the implementation of the reform and has persisted over time.ConclusionGovernments in numerous European and North American jurisdictions have introduced measures to further diminish the generosity and coverage of welfare benefits. In line with growing concerns over the potential consequences of austerity and associated policy measures, our findings suggest that these reform efforts pose a threat to the health of socioeconomically disadvantaged populations.

BackgroundCOVID-19 has exploited the inequities within the US housing system. Examining the association between housing and health during the pandemic is imperative to reducing health inequities and improving population health.MethodsWe analysed 957 714 responses from the Household Pulse Survey Study, collected between April and July 2020. Using survey-weighted multivariable regression analyses, we assessed the relationships between housing tenure and health, both on average and over time, as well as how these relationships were moderated by COVID-19-related hardships including job loss, food insecurity and inability to afford housing-related costs. We controlled for a variety of potential socioeconomic and demographic confounding factors.ResultsWe found that housing tenure was significantly associated with both self-rated health and mental distress. Compared with homeowners without mortgage debt, homeowners with mortgage debt reported worse self-rated health (β=−0.13; 95% CI −0.15 to −0.12, pConclusionsThese results add to a limited body of evidence suggesting that, during this period, housing instability and COVID-19-related hardships have contributed to an increase in health inequities in the USA.

BackgroundPrecarious employment has increased in Germany by means of labour market flexibilisation throughout the 1990s and 2000s. In this study, trends in the association of self-rated health (SRH) with different dimensions of precarious employment by gender in Germany between 1995 and 2015 were assessed considering different periods of labour market reforms and the Great Recession.MethodsAnalyses were conducted using the German Socio-Economic Panel from 1995 to 2015. All employed individuals aged 18–67 years and living in private households were considered for analysis to examine the risks of poor SRH by low wage, working poverty, non-standard working time arrangements and perceived job insecurity by gender. Predicted probabilities, adjusted risk ratio (ARR), adjusted risk difference (ARD) and trends were examined using pooled interval logistic regression with individual-clustered standard errors.ResultsRelative and absolute differences in SRH rose significantly over time by perceived job insecurity for men, but not for women. Working poverty appeared to be significantly associated with SRH in the Great Recession and the post-Recession period for both gender. Non-standard working time arrangements were not significantly associated with SRH for both gender, and low wage appeared to be significantly associated with SRH only for men in the post-Recession period.ConclusionsThe results highlighted the relevance of labour market reforms of deregulation and flexibilisation in Germany to differences in SRH by specific forms of precarious employment and gender differences in the impact of labour market reforms on precarious employment and health.

BackgroundAlthough there is evidence for socioeconomic inequalities in health and health behaviour in adolescents, different indicators of socioeconomic status (SES) have rarely been compared within one data sample. We examined associations of five SES indicators with self-rated health (SRH) and smoking (ie, a leading cause of health inequalities) in Europe.MethodsData of adolescents aged 14–17 years old were obtained from the 2013 SILNE survey (smoking inequalities: learning from natural experiments), carried out in 50 schools in 6 European cities (N=10 900). Capturing subjective perceptions of relative SES and objective measures of education and wealth, we measured adolescents’ own SES (academic performance, pocket money), parental SES (parental educational level) and family SES (Family Affluence Scale, subjective social status (SSS)). Logistic regression models with SRH and smoking as dependent variables included all SES indicators, age and gender.ResultsCorrelations between SES indicators were weak to moderate. Low academic performance (OR=1.96, 95% CI 1.53 to 2.51) and low SSS (OR=2.75, 95% CI 2.12 to 3.55) were the strongest indicators of poor SRH after adjusting for other SES-indicators. Results for SSS were consistent across countries, while associations with academic performance varied. Low academic performance (OR=5.71, 95% CI 4.63 to 7.06) and more pocket money (OR=0.21, 95% CI 0.18 to 0.26) were most strongly associated with smoking in all countries.ConclusionsSocioeconomic inequalities in adolescent health were largest according to SES indicators more closely related to the adolescent’s education as well as the adolescent’s perception of relative family SES, rather than objective indicators of parental education and material family affluence. For future studies on adolescent health inequalities, consideration of adolescent-related SES indicators was recommended.

BackgroundLittle is known about the impact of being a bystander to bullying. This study compared health outcomes among bullies, victims and bystanders, and investigated actions taken by bystanders when they saw bullying.MethodParticipants included 7522 students aged 12–18 years that completed self-report questionnaires in the 2013/2014 Health Behaviour in School-aged Children survey. Binary logistic regression models (controlled for bully, victim, bystander status and demographic variables) were used to investigate the associations between participation in bullying as a bully, victim and bystander and health outcomes.ResultsOverall, 13.3% of adolescents reported being a bully, 25.1% reported being a victim and 30.5% reported that they saw bullying, in the last couple of months. Bystanders were significantly more likely to experience psychological symptoms (OR 1.355), somatic symptoms (OR 1.392) and low life satisfaction (OR 1.268) than those who were not bystanders. Helping the victim was significantly associated with experiencing psychological symptoms (OR 1.240), somatic symptoms (OR 1.251) and low life satisfaction (OR 1.198). Being a bully was significantly associated with experiencing psychological symptoms (OR 1.382) and not having excellent health (OR 1.252). Victims were significantly more likely to experience psychological symptoms (OR 2.437), somatic symptoms (OR 2.364), low life satisfaction (OR 2.564) and not having excellent health (OR 1.559).ConclusionIn Ireland, being a bystander to bullying is more prevalent in schools than bullying perpetration or victimisation. The impact of being a bystander to bullying needs to be highlighted and included in intervention development.

Background Social capital may be a social good in health terms, but it is not necessarily a universal good. Several studies have shown that while there is a positive association between ecological social capital and health in people with high individual-level social capital, this relationship is weaker or even reversed in those with low individual-level social capital. Such studies, however, have used relatively coarse levels of geography for quantifying ecological social capital. The present study looks at this relationship at a more fine-grained spatial scale. Methods Data from the National Survey for Wales (n=27 828, weighted mean age=48.4) were linked to previously published small-area estimates (n=410) of ecological social capital for Wales. Mixed effects models were then used to assess whether the relationship between mental well-being and self-reported health on one hand, and ecological social capital (sense of belonging) on the other, was moderated by individual-level social capital. Results The models found the same moderation of the relationship that has been demonstrated previously: Although ecological social capital is positively associated with health in respondents with high individual-level social capital, the relationship is negative in those with low individual-level social capital. Conclusion This study replicates this association at a spatial scale orders of magnitude more fine-grained than had been shown previously. Ecological social capital is not an unambiguously positive factor for public health, and may be a risk factor for marginalised people.

BackgroundHealthy life expectancy (HLE) is a population health measure that combines mortality and morbidity, which can be calculated using different methods. In this study, we aimed to assess the correlation, reliability and (dis)agreement between two estimates monitored in the European Union (EU), that is, the European Commission's HLE based on self-perceived health (SPH-HLE) and the Institute for Health Metrics and Evaluation's HLE based on disability weight (DW-HLE), by sex, and comparing these results with LE and proportion of life spent in good health (%GH).MethodsWe performed a retrospective study in the EU28 countries, between 2010 and 2017. The HLE methods differ in definition, measurement and valuation of health states. While SPH-HLE relies directly on one question, DW-HLE relies on epidemiological data adjusted for DW. Spearman’s r, intraclass correlation coefficient, information-based measure of disagreement and Bland-Altman plots were used to assess reliability, correlation and disagreement in HLE resulting from both methods and in LE or %GH measured by both institutions.ResultsCorrelation and reliability between SPH-HLE and DW-HLE were good (better for males), with low disagreement, and were even better for LE between both institutions. The HLE Bland-Altman plots suggest a variability range of approximately 6 years for both sexes, higher for females. There was also an increasing HLE difference between methods with higher average HLE for both sexes.ConclusionWe showed wide variations between both methods with a clear and different high impact on female and male HLE, showing a tendency for countries with higher health expectancies to yield larger gaps between SPH-HLE and DW-HLE.

BackgroundFrom a theoretical perspective, several studies indicate that happiness and health are—in some extent—interrelated. Despite the mechanisms explaining the relationship between happiness and health, there is still no consensus regarding this link. Using recently collected primary data, this study aims to examine the relationship between happiness and health, and identify potential heterogeneity in the association depending on socioeconomic status (SES).MethodsThis study draws on data from a nationally representative cross-sectional survey, conducted by the Greek National School of Public Health in 2015. We applied an instrumental variable (IV) approach to address the endogeneity, arising from the simultaneous determination of happiness and health. Controlling for several confounders (ie, socioeconomic, demographic, lifestyle, social capital variables) we employed several IV models, including two-stage least squares, IV probit and bivariate probit models.ResultsWe report strong evidence of a relationship between happiness and health. This association remains strong after correcting for endogeneity, and is robust across different specifications. Further, we find a positive relationship between happiness and self-rated health (SRH) for low educated, but not for high educated. Similarly, we find a strong relationship between happiness and health for the lower socioeconomic strata, but not for the higher ones.ConclusionsOverall, we show that happiness is positively associated with health. Further, happiness significantly influences SRH in low-SES individuals, but this association wanes for the higher socioeconomic strata. This finding has significant implications for health promotion, prevention and public health, and suggests that policymakers have a wider array of choices for improving health and tackling health inequalities.

Background Lone parenthood is associated with poorer health; however, the vast majority of previous studies have examined lone mothers and only a few have focused on lone fathers. We aimed to examine the self-rated health and mental health status among a large population-based cross-sectional sample of Canadian lone fathers compared with both partnered fathers and lone mothers. Methods We investigated differences in self-rated health and mental health among 1058 lone fathers compared with 20 692 partnered fathers and 5725 lone mothers using the Ontario component of the Canadian Community Health Survey (2001–2013). Multivariable logistic regression was used to compare the odds of poor/fair self-rated health and mental health between the study groups while adjusting for a comprehensive list of sociodemographic factors, stressors and lifestyle factors. Results Lone fathers and lone mothers showed similar prevalence of poor/fair self-rated health (11.6% and 12.5%, respectively) and mental health (6.2% and 8.4%, respectively); the odds were similar even after multivariable adjustment. Lone fathers showed higher odds of poor/fair self-rated health (OR 1.53, 95% CI 1.07 to 2.17) and mental health (OR 2.09, 95% CI 1.26 to 3.46) than partnered fathers after adjustment for sociodemographic factors; however, these differences were no longer significant after accounting for stressors, including low income and unemployment. Conclusions In this large population-based study, lone fathers had worse self-rated health and mental health than partnered fathers and similarly poor self-rated health and mental health as lone mothers. Interventions, supports and social policies designed for single parents should also recognise the needs of lone fathers.

IntroductionThe health of the British population has been shown to be worsening by self-reported health and improving by self-reported limiting illness for those born before and after 1945. Little is known about the inequality in health difference across British birth cohorts by income.MethodsRepeated cross-sections from the British General Household Survey, 1979–2011, are used to create pseudo birth cohorts born, 1920–1970, and their gender stratified, age-adjusted limiting illness and self-rated health (SRH) are estimated by household income tertiles. Absolute and relative differences between the poorest and richest income groups are reported.ResultsAbsolute inequalities in limiting illness between the richest and poorest households have doubled in women and increased by one and a half times in men for those born in 1920–1922 compared with those born in 1968–1970. Relative inequalities in limiting illness increased by a half in women and doubled in men. Absolute inequalities in SRH between the richest and poorest households increased by almost half in women and more than half in men and relative inequalities increased by 18% in women and 14% in men for those born in 1920–1922 compared with those born in 1968–1970.ConclusionInequalities in self-reported health at the same age by household income have widened for successively later-born British cohorts.

Background We estimate the intergenerational relationship between the residential school (RS) attendance of an older generation family member and the physical and mental health of a younger generation. Methods Data from the 2012 Aboriginal Peoples Survey (APS) is used to examine the relationship between previous generational family RS attendance and the current physical and mental health of off-reserve First Nations, Metis and Inuit Canadians. Five outcomes are considered (self-perceived health, mental health, distress, suicidal ideation and suicide attempt). Direct (univariate) and indirect (multivariate) effects of family RS attendance are examined for each dependent variable. We draw from the general and indigenous-specific social determinants of health literature to inform the construction of our models. Results Familial RS attendance is shown to affect directly all five health and mental health outcomes, and is associated with lower self-perceived health and mental health, and a higher risk for distress and suicidal behaviours. Background, mediating and structural-level variables influence the strength of association. Odds of being in lower self-perceived health remain statistically significantly higher with the presence of familial attendance of RS when controlling for all covariates. The odds of having had a suicide attempt within the past 12 months remain twice as high for those with familial attendance of RS. Conclusions Health disparities exist between indigenous and non-indigenous Canadians, an important source of which is a family history of RS attendance. This has implications for clinical practice and Canadian public health, as well as countries with similar historical legacies.

Background Social support is associated with better health. However, only a limited number of studies have examined the association of social support with health from the adult life course perspective and whether this association is bidirectional. Methods Participants (n=6797; 30% women; age range from 40 to 77 years) who were followed from 1989 (phase 2) to 2006 (phase 8) were selected from the ongoing Whitehall II Study. Structural and functional social support was measured at follow-up phases 2, 5 and 7. Mental and physical health was measured at five consecutive follow-up phases (3–8). Results Social support predicted better mental health, and certain functional aspects of social support, such as higher practical support and higher levels of negative aspects in social relationships, predicted poorer physical health. The association between negative aspects of close relationships and physical health was found to strengthen over the adult life course. In women, the association between marital status and mental health weakened until the age of approximately 60 years. Better mental and physical health was associated with higher future social support. Conclusions The strength of the association between social support and health may vary over the adult life course. The association with health seems to be bidirectional.

BACKGROUND: Between the 1990s and 2000s, relative inequalities in all-cause mortality increased, whereas absolute inequalities decreased in many European countries. Whether similar trends can be observed for inequalities in other health outcomes is unknown. This paper aims to provide a comprehensive overview of trends in socioeconomic inequalities in self-assessed health (SAH) in Europe between 1990 and 2010.METHODS: Data were obtained from nationally representative surveys from 17 European countries for the various years between 1990 and 2010. The age-standardised prevalence of less-than-good SAH was analysed by education and occupation among men and women aged 30-79 years. Socioeconomic inequalities were measured by means of absolute rate differences and relative rate ratios. Meta-analysis with random-effects models was used to examine the trends of inequalities.RESULTS: We observed declining trends in the prevalence of less-than-good SAH in many countries, particularly in Southern and Eastern Europe and the Baltic states. In all countries, less-than-good SAH was more prevalent in lower educational and manual groups. For all countries together, absolute inequalities in SAH were mostly constant, whereas relative inequalities increased. Almost no country consistently experienced a significant decline in either absolute or relative inequalities.CONCLUSIONS: Trends in inequalities in SAH in Europe were generally less favourable than those found for inequalities in mortality, and there was generally no correspondence between the two when we compared the trends within countries. In order to develop policies or interventions that effectively reduce inequalities in SAH, a better understanding of the causes of these inequalities is needed.

BackgroundPrevious research association increased levels of cultural continuity and decreased rates of youth suicide in First Nations communities. We investigate the relationship between cultural continuity and self-rated health looking specifically at Inuit living in the Canadian Arctic.MethodsThe Arctic Supplements of the Aboriginal Peoples Survey from years 2001 and 2006 were appended to explore the relationship between various measures of cultural continuity and self-rated health. These measures include access to government services in an Aboriginal language, Inuit cultural variables, community involvement and governance. Literature related to Inuit social determinants of health and health-related behaviours were used to build the models.ResultsAll measures of cultural continuity were shown to have a positive association with self-rated health for Inuit participants. Background and other control variables influenced the strength of the association but not the direction of the association. Access to services in an Aboriginal language, harvesting activities and government satisfaction were all significantly related to the odds of better health outcomes. Finally, the study contributes a baseline from a known data horizon against which future studies can assess changes and understand future impacts of changes.ConclusionThe Canadian government and other agencies should address health inequalities between Inuit and non-Inuit people through programmes designed to foster cultural continuity at a community level. Providing access to services in an Aboriginal language is a superficial way of promoting cultural alignment of these services; however, more inclusion of Inuit traditional knowledge is needed to have a positive influence on health.

BackgroundInterest in monitoring health-related quality of life (HRQoL) in general populations has increased in the past 20 years, reinforced by population ageing and repeated economic crises. This study aims to identify temporal trends in HRQoL in France between 1995 and 2016 and to assess disparities according to demographic and socioeconomic characteristics.MethodsData from repeated population-based cross-sectional surveys conducted in 1995, 2003 and 2016 were used. HRQoL was measured using the Medical Outcomes Study 36-item Short Form (SF-36) questionnaire.ResultsA substantial decrease in score was observed between 1995 and 2016 for both genders in almost all subscales of the SF-36, with the largest decrease being in the mental health dimension for men. However, the age group 18–54 years were the most affected with persistent negative or even worsening trends in HRQoL. The largest decreases were among men aged 45–54 years and women aged 35–44 years in most dimensions, and among the age group 18–24 years in vitality. Conversely, an overall improvement was noted among the age group 65–84 years. People in employment were more affected than the unemployed by the decline in several HRQoL dimensions.ConclusionA general decline in HRQoL was found between 1995 and 2016 in the French population, but with wide disparities in trends between age groups. Young and especially middle-aged, employed people exhibited persistent negative and worsening trends. Consistent with evidence from traditional mental health morbidity and mortality indicators, our findings raise questions about the potential influence of macro-socioeconomic factors, especially the 2008 crisis; these observations deserve special attention from health policy-makers.

BackgroundDue to the sustained increases in life expectancy over the past half century, the elderly today will receive supports from their children for a longer period than ever before. Therefore, understanding the spillover effects of children’s socioeconomic status on parents’ health becomes increasingly important for both scholars and policy makers.MethodsThe Ordinary Least Squares regression is applied to the China Health and Retirement Longitudinal Study 2011, a national representative dataset including approximately 10 000 households and 17 600 middle-aged and elderly respondents. The Sobel test is used to examine the mediation role of social integration.ResultsThe elderly who have a cadre child reported better health (coefficient=0.1347; 95% CI 0.067 to 0.202), had fewer activities of daily living (ADLs) limitations (coefficient=−0.1289; 95% CI −0.216 to −0.042) and were more socially integrated (coefficient=0.2321; 95% CI 0.103 to 0.361). Such effects are mainly driven by the parents of higher-ranking cadres. For the parents of higher ranking cadres, the Sobel test suggests that 12.6% of the total effects on self-reported health and 21.9% of the total effects on ADL limitations are mediated by the increase in parents’ social integration.ConclusionThe findings suggest positive spillover effects of children’s political status on parents’ health. The benefits of having a cadre child are at least equivalent to the rural–urban gap in health and even stronger for the parents of higher ranking cadres. One potential explanation for such spillover effects is that a child’s political status can improve parents’ community involvement and social interactions.

Background Those interested in evaluating the effectiveness of community interventions on health and well-being need information about what tools are available and best suited to measure improvements that could be attributed to the intervention. This study evaluated published measurement tools of health and well-being that have the potential to be used before and after an intervention. Methods A literature search of health and sociological databases was undertaken for articles that utilised measurement tools in community settings to measure overall health, well-being or quality of life. Articles were considered potentially relevant because they included use of measurement tools related to general health or well-being. These tools were evaluated by further searching of the literature to assess each tool9s properties including: reliability; validity; responsiveness; length; use in cross-cultural settings; global health or well-being assessment; use of subjective measures; clarity and cost. A composite score was made based on the average rating of all fields. Results Of 958 abstracts that were screened, 123 articles were extracted for review. From those articles, 27 measurement tools were selected and assessed. Based on the composite score assessing across all domains, five tools were rated as excellent. Conclusions While tools may need to be selected for particular aims and interventions, a range of potential well-described tools already exist and should be considered for use in preference to ad hoc or bespoke tools. Any of the five tools rated as excellent are recommended to assess the impact of a community intervention.

Background It was supposed that associations of wealth and health might be higher after retirement than in the economically active periods of life, but no comparisons were available. Most studies on wealth were based on net worth, a measure combining several elements of wealth into an index. We examined associations between different elements of wealth and health by comparing retired women and men with economically active ones. Method Data were drawn from the German Socio-Economic Panel, a nationwide longitudinal survey project. Two waves (2002 and 2007) included indicators of wealth in addition to household income and education. Wealth was not depicted by an index. Instead, debts, property of life insurances, home ownership and assets were considered separately with their associations with self-rated health. Two data sets were used to examine whether the results were occasional, or whether they can be replicated. Results Associations of income and education emerged in respondents in their active periods of life. In most cases indicators of wealth were associated with subjective health. In retired respondents home ownership was the only indicator yielding consistent associations with health, but their sizes turned out as rather moderate. Conclusions Contrary to expectation, the associations of wealth and health were inconsistent in the retired study population. These results were obtained in a country with national pension schemes, and it has to be examined whether the findings can be generalised to other countries. The inconsistent findings of indicators of wealth are calling the utility of net worth into question.

Background The late-2000s financial crisis had a severe impact on the national economies on a global scale. In Europe, the Baltic countries were among those most affected with more than a 20% decrease in per capita gross domestic product in 2008–2009. In this study, we explored the effects of economic recession on self-rated health in Estonia and Lithuania using Finland, a neighbouring Nordic welfare state, as a point of reference. Methods Nationally representative cross-sectional data for Estonia (n=10 966), Lithuania (n=7249) and Finland (n=11 602) for 2004–2010 were analysed for changes in age-standardised prevalence rates of less-than-good self-rated health and changes in health inequalities using logistic regression analysis. Results The prevalence of less-than-good self-rated health increased slightly (albeit not statistically significantly) in all countries during 2008–2010. This was in sharp contrast to the statistically significant decline in the prevalence of less-than-good health in 2004–2008 in Estonia and Lithuania. Health disparities were larger in Estonia and Lithuania when compared to Finland, but decreased in 2008–2010 (in men only). In Finland, both the prevalence of less-than-good health and health disparities remained fairly stable throughout the period. Conclusions Despite the rapid economic downturn, the short-term health effects in Estonia and Lithuania did not differ from those in Finland, although the recession years marked the end of the previous positive trend in self-rated health. The reduction in health disparities during the recession indicates that different socioeconomic groups were affected disproportionately; however, the reasons for this require further research.

Background Japan, for the past two decades, has seen economic stagnation and substantial social change. We examined whether health inequalities increased over this period. Methods Using eight triennial waves of a series of large nationally representative surveys between 1986 and 2007 (n=398 303), temporal trends in relative and slope indices of inequality (RII, SII, respectively) were tested based on self-rated health in relation to theory-based social class and household income. Results Age-standardised prevalence of self-rated fair or poor health showed V-shaped time trends in both sexes with the lowest prevalence in early/mid-1990s. In 1986, RII and SII in household social class and income were significant for both sexes. In men, RII and SII according to income showed significant narrowing of temporal trends in poor health (−1.4% and −0.1% annually, respectively), but these were stable in women. After multilevel multiple imputation for missing income data, the findings in men were not altered but narrowing trends became evident and significant in women (−1% and −0.1% annually, respectively). Inequality indices for social class remained constant over the study period in both sexes. Conclusions Relative and absolute health inequalities for social class and income based on self-rated fair or poor health narrowed or remained stable between 1986 and 2007, despite the economic stagnation and adverse social changes. Overall population health across socioeconomic groups initially improved but then worsened. The positive finding regarding the health inequality trend seen in the Japanese context is informative for the wider international community during this period of economic uncertainty.

Background Social exclusion of the elderly is a key policy focus but evidence on the processes linking health and social exclusion is hampered by the variety of ways that health is used in social exclusion research. We investigated longitudinal associations between health and social exclusion using an analytical framework that did not conflate them. Methods Data employed in this study came from 4 waves of Understanding Society, the UK Household Longitudinal Study 2009–2013. The sample comprised all adults who took part in all 4 waves, were 65 years or more in Wave 3, and had complete data on our variables of interest for each analysis. We used linear regression to model the relationship between Wave 2/3 social exclusion and Wave1–2 health transitions (N=4312) and logistic regression to model the relationship between Wave2/3 social exclusion and Wave 4 health states, conditional on Wave 3 health (N=4244). Results There was a dose–response relationship between poor health in Waves 1 and 2 and later social exclusion. Use of a car, mobile phone and the internet moderated the association between poor health and social exclusion. Given the health status in Wave 3, those who were more socially excluded had poorer outcomes on each of the three domains of health in Wave 4. Conclusions Use of the internet and technology protected older adults in poor health from social exclusion. Age-friendly hardware and software design might have public health benefits.

Background Material, psychosocial and behavioural factors are important explanatory pathways for socioeconomic inequalities in health. The aim of this systematic review was to summarise the available evidence on empirical studies and to analyse the relative contribution of these factors for explaining inequalities in self-rated health. Methods The study was performed in compliance with PRISMA guidelines. The literature search was conducted in the electronic databases PubMed and Web of Science (1996–2016) as well as by screening of reference lists of obtained articles. Two reviewers performed the search and critical appraisal of the studies. All studies that focus on explaining socioeconomic inequalities in self-rated health, including at least 2 of the 3 main pathways and analysing the relative contribution of these approaches in separate and joint models, were included. Results Eleven publications were included. Separate analyses showed that material, psychosocial and behavioural factors contribute to the explanation of socioeconomic inequalities in self-rated health. However, the combined analyses revealed that material factors contributed most to differences in self-rated health because of their higher independent (direct) effect and additional shared (indirect) effect (through psychosocial and behavioural factors). These results were largely independent of age, gender and indicator of socioeconomic status. Conclusions The evidence presented might be used for policymakers to identify and to justify prioritisation in terms of prevention and health promotion. The findings show that multiple factors are important for tackling social inequalities in health. Strategies for reducing these inequalities should focus on material/structural living conditions as they shape conditions of psychosocial resources and health behaviour.

Background Efforts to explain social inequalities in health have mainly focused on adults. Few studies have systematically analysed different explanatory pathways in adolescence. This study is among the first to examine the contribution of material, psychosocial and behavioural factors in the explanation of inequalities in adolescent health. Methods Data were obtained from the German part of the cross-sectional ‘Health Behaviour in School-aged Children’ Survey in 2006, with a total of 6997 respondents aged 11–15 years (response rate 86%). Socioeconomic position was measured using the Family Affluence Scale. Multistage logistic regression models were used to assess the relative importance of explanatory factors. Results Compared with adolescents from high affluent backgrounds, the ORs of fair/poor self-rated health increased to 1.53 (95% CI 1.11 to 2.12) in low affluent boys and to 2.08 (95% CI 1.62 to 2.67) in low affluent girls. In the separate analyses, material, psychosocial and behavioural factors attenuated the OR by 30–50%. Together, the three explanatory factors reduced the OR by about 80% in low affluent boys and girls. The combined analyses illustrated that material factors contributed most to the differences in self-rated health because of their direct and indirect effect (through psychosocial and behavioural factors). Conclusions The findings show that the main explanatory approaches for adults also apply to adolescents. The direct and indirect contribution of material factors for inequalities in self-rated health was stronger than that of behavioural and psychosocial factors. Strategies for reducing health inequalities should primarily focus on improving material circumstances in lower affluent groups.

Measuring the distribution of health is a part of assessing health system performance. This study aims to estimate health inequality between different socioeconomic groups and its determinants in Tehran, the capital of Iran.Self-rated health (SRH) and demographic characteristics, including gender, age, marital status, educational years, and assets, were measured by structured interviews of 2464 residents of Tehran in 2008. A concentration index was calculated to measure health inequality by economic status. The association of potential determinants and SRH was assessed through multivariate logistic regression. The contribution to concentration index of level of education, marital status and other determining factors was assessed by decomposition.The mean age of respondents was 41.4 years (SD 17.7) and 49% of them were men. The mean score of SRH status was 3.72 (range: 1-5; SD 0.93). 282 respondents (11.5%) rated their health status as poor or very poor. The concentration index was -0.29 (SE 0.03; p0.001). Age, marital status, level of education and household economic status were significantly associated with SRH in both the crude and adjusted analyses. The main contributors to inequality in SRH were economic status (47.8%), level of education (29.2%) and age (23.0%).Sub-optimal SRH was more in lower than in higher economic status. After controlling for age, the levels of education and household wealth have the greatest contributions to SRH inequality.

Background Few studies have examined the potential difference in the relationship between bonding versus bridging social capital and health outcomes. We sought to examine the association between these different types of social capital and self-rated health in a population-based study. Methods In February 2009, 4000 residents of Okayama City (aged 20e80 y) were randomly selected for a survey on social capital and health. The survey asked about participation in six different types of associations: Parents and Teachers Association, sports clubs, alumni associations, political campaign clubs, citizen’s groups and community associations. We distinguished between bonding and bridging social capital by asking participants about their perceived homogeneity (with respect to gender, age and occupation) of the groups they belonged to. ORs and 95% CIs for poor health were calculated. Results Bridging social capital (ie, participation in groups involving people from a diversity of backgrounds) was inversely associated with poor health in both sexes and women appeared to benefit more than men. Compared to those who reported zero participation, high bridging social capital was associated with a reduced odds of poor health (OR 0.25, 95% CI 0.11 to 0.55) in women after controlling for demographic variables, socioeconomic status, smoking habit and overweight. By contrast, bonding social capital was not consistently associated with better health in either gender. Conclusions The present study suggests that bonding and bridging social capital have differential associations with health and that the two forms of social capital need to be distinguished in considering interventions to promote health.

Objective: To investigate if job insecurity and poor labour market chances predict a decline in self-rated health in the Danish workforce.Design: Job insecurity, labour market chances, self-rated health and numerous covariates were measured in 1809 women and 1918 men who responded to a questionnaire in 1995 and again in 2000. Multivariate logistic regression analyses were used to analyse the impact of job insecurity and labour market chances measured in 1995 on decline in health in 2000.Setting: Prospective cohort study with a representative sample of the Danish workforce using the Danish Work Environment Cohort Study (DWECS). All participants were employed at baseline.Main results: Women with job insecurity had an increased risk of a decline in health at follow-up, after adjustment for all covariates (OR = 1.78, 95% CI: 1.24 to 2.54). Effect estimates were strongest among women 50 years of age or younger with poor labour market chances (OR = 2.13, 95% CI: 1.32 to 3.45). Among men, there was no main effect for job insecurity. However, men aged 50 years or younger with poor labour market chances showed an OR of 1.64 (95% CI: 0.95 to 2.84) for a decline in health.Conclusion: Job insecurity is a predictor for a decline in health in employed women in Denmark. Among men, a suggestive effect of job insecurity was found in employees aged 50 years or younger with poor labour market chances.

Background Older people who drink have been shown to have better health than those who do not. This might suggest that moderate drinking is beneficial for health, or, as considered here, that older people modify their drinking as their health deteriorates. The relationship between how often older adults drink and their health is considered for two heath states: self-rated health (SRH) and depressive symptoms. Methods Data were analysed from the English Longitudinal Study of Ageing (ELSA), a prospective cohort study of older adults, using multilevel ordered logit analysis. The analysis involved 4741 participants present at wave 0, (1998/1999 and 2001), wave 4 (2008/2009) and wave 5 (2010/2011). The outcome measure was frequency of drinking in last year recorded at all three time points. Results Older adults with fair/poor SRH at the onset of the study drank less frequently compared with adults with good SRH (p

Background It is well known that individual-level social capital is positively associated with health, but most preceding studies have not fully controlled for an individual9s time-invariant attributes, especially unobserved ones. The current study attempted to address how the association between individual-level social capital and health is confounded by an individual9s unobserved time-invariant attributes. Methods Data were collected from six-wave nationwide panel surveys conducted from 2005 to 2010, with 162 720 observations from 30 590 individuals. Individual-level bonding and bridging social capital, as well as their associations with self-rated health (SRH) and psychological distress (measured by Kessler 6 scores), were considered. Estimation results of cross-sectional, prospective cohort and fixed-effects logistic models were compared. Results The OR of reporting poor SRH responding to high bonding social capital rose from 0.64 (95% CI 0.62 to 0.65) in the pooled cross-sectional model to 0.77 (0.75 to 0.80) in the prospective cohort model and 0.87 (0.82 to 0.92) in the fixed-effects model. Similar patterns were observed for bridging social capital, but the OR of reporting poor SRH became non-significant in the fixed-effects model. Similar results were obtained for psychological distress. Conclusions The results suggest that the association between individual-level social capital and health is overstated by an individual9s unobserved time-invariant attributes. The relevance of health in individual-level social capital should be assessed cautiously.

Background Research on inequalities in health has shown a strong association between the lack of standard of living (defined as material deprivation) and self-rated health (SRH). In this study, we sought to further examine this association in a trend analysis of relative and absolute inequalities in SRH as defined by material deprivation in Germany. Methods Data were obtained from the German Socio-Economic Panel (GSOEP) between 2001 and 2011. Material deprivation was measured on the basis of 11 living standard items missing due to financial reasons. We used the relative index of inequality (RII) and slope index of inequality (SII) to measure inequalities in SRH by material deprivation, calculating pooled interval logistic regression with robust SEs. Stepwise models were estimated, including demographic and socioeconomic variables, to assess their inter-relation with inequalities in SRH by material deprivation. Results The results showed a steady increase in poor SRH over the 10-year duration of the study. A quadratic (inverted U-shaped) trend was observed in material deprivation in the standards of living, which rose from 2001 to 2005, and then declined in 2011. A similar but non-significant trend was found in relative and absolute inequalities in SRH by material deprivation, which increased from 2001 to 2005 and then declined. Conclusions Inequality in SRH by material deprivation was relatively stable; however, an observed quadratic trend coincided with active and passive labour market reforms in Germany in early 2005.

Background Social capital research has consistently shown positive associations between generalised trust and health outcomes over 2 decades. Longitudinal studies attempting to test causal relationships further support the theory that trust is an independent predictor of health. However, as the reverse causality hypothesis has yet to be empirically tested, a knowledge gap remains. The aim of this study, therefore, was to investigate if health status predicts trust. Methods Data employed in this study came from 4 waves of the British Household Panel Survey between years 2000 and 2007 (N=8114). The sample was stratified by baseline trust to investigate temporal relationships between prior self-rated health (SRH) and changes in trust. We used logistic regression models with random effects, as trust was expected to be more similar within the same individuals over time. Results From the ‘Can trust at baseline’ cohort, poor SRH at time (t−1) predicted low trust at time (t) (OR=1.38). Likewise, good health predicted high trust within the ‘Cannot’ trust cohort (OR=1.30). These patterns of positive association remained after robustness checks, which adjusted for misclassification of outcome (trust) status and the existence of other temporal pathways. Conclusions This study offers empirical evidence to support the circular nature of trust/health relationship. The stability of association between prior health status and changes in trust over time differed between cohorts, hinting at the existence of complex pathways rather than a simple positive feedback loop.

Contains fulltext : 58321.pdf (Publisher’s version ) (Closed access) STUDY OBJECTIVE: To identify risk factors of the development of the chronic fatigue syndrome (CFS), the persistence or recurrence of fatigue, or recovery from fatigue in a large sample of fatigued employees. DESIGN: Analyses were based on the Maastricht cohort study (MCS), a prospective population based cohort study among more than 12 000 employees. Multiple regression models were used to identify predictors of CFS-like caseness (meeting research criteria for CFS), non-CFS fatigue caseness, or no fatigue caseness. SETTING: The working population in the Netherlands. PARTICIPANTS: 1143 employees with medically unexplained fatigue were followed up prospectively for 44 months. MAIN RESULTS: At 44 month follow up, 8% of the employees were CFS-like cases (none of who reported to have received a CFS diagnosis), 40% were non-CFS fatigue cases, and 52% were no longer fatigue cases. Factors that predicted CFS-like caseness compared with non-CFS fatigue caseness were high age, exhaustion, female sex, low education, and visits to the general practitioner. Factors that predicted CFS-like caseness compared with no fatigue caseness were fatigue, exhaustion, low education, visits to the GP and occupational physician, and bad self rated health. Factors that predicted non-CFS fatigue caseness compared with no fatigue caseness were fatigue, low self perceived activity, exhaustion, anxious mood, and bad self rated health. CONCLUSIONS: Unexplained fatigue among employees in some instances is a precursor of the development of CFS. The prognostic role of self rated health suggests that prevention and treatment of chronic fatigue should be aimed at changing the perception of health or illness. Less clear is the role of health care seeking or receiving a CFS diagnosis.

Background The objective of this study was to examine the relative contribution of factors explaining ethnic health inequalities (EHI) in poor self-reported health (pSRH) and limiting long-standing illness (LLI) between Health Survey for England (HSE) participants. Method Using HSE 2003–2006 data, the odds of reporting pSRH or of LLI in 8573 Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Irish and Pakistani participants was compared with 28 470 White British participants. The effects of demographics, socioeconomic position (SEP), psychosocial variables, community characteristics and health behaviours were assessed using separate regression models. Results Compared with White British men, age-adjusted odds (OR, 95% CI) of pSRH were higher among Bangladeshi (2.05, 1.34 to 3.14), Pakistani (1.77, 1.34 to 2.33) and Black Caribbean (1.60, 1.18 to 2.18) men, but these became non-significant following adjustment for SEP and health behaviours. Unlike Black Caribbean men, Black African men exhibited a lower risk of age-adjusted pSRH (0.66, 0.43 to 1.00 (p=0.048)) and LLI (0.45, 0.28 to 0.72), which were significant in every model. Likewise, Chinese men had a lower risk of age-adjusted pSRH (0.51, 0.26 to 1.00 (p=0.048)) and LLI (0.22, 0.10 to 0.48). Except in Black Caribbean women, adjustment for SEP rendered raised age-adjusted associations for pSRH among Pakistani (2.51, 1.99 to 3.17), Bangladeshi (1.85, 1.08 to 3.16), Black Caribbean (1.78, 1.44 to 2.21) and Indian women (1.37, 1.13 to 1.66) insignificant. Adjustment for health behaviours had the largest effect for South Asian women. By contrast, Irish women reported better age-adjusted SRH (0.70, 1.51 to 0.96). Conclusions SEP and health behaviours were major contributors explaining EHI. Policies to improve health equity need to monitor these pathways and be informed by them.

Background The global financial crisis of 2008 is likely to have repercussions on public health in Europe, not least through escalating mass unemployment, fiscal austerity measures and inadequate social protection systems. The purpose of this study is to analyse the role of unemployment insurance for deteriorating self-rated health in the working age population at the onset of the fiscal crisis in Europe. Methods Multilevel logistic conditional change models linking institutional-level data on coverage and income replacement in unemployment insurance to individual-level panel data on self-rated health in 23 European countries at two repeated occasions, 2006 and 2009. Results Unemployment insurance significantly reduces transitions into self-rated ill-health and, particularly, programme coverage is important in this respect. Unemployment insurance is also of relevance for the socioeconomic gradients of health at individual level, where programme coverage significantly reduces health risks attached to educational attainment. Conclusions Unemployment insurance mitigated adverse health effects both at individual and country-level during the financial crisis. Due to the centrality of programme coverage, reforms to unemployment insurance should focus on extending the number of insured people in the labour force.