Final Report Summary - SOPHIE (EVALUATING THE IMPACT OF STRUCTURAL POLICIES ON HEALTH INEQUALITIES AND THEIR SOCIAL DETERMINANTS AND FOSTERING CHANGE)
Executive Summary:
Social and economic policies can change the extent of social inequalities in health
During these years, SOPHIE has contributed to the accumulation of evidence regarding the influence of social and economic policies on the level of health of the population and on the extent of inequalities in health status on grounds of socioeconomic position, gender or immigrant background. At the same time, SOPHIE has shown, through the analysis of several examples across Europe, how equity-oriented policies can achieve a reduction of these health inequalities. These studies provide a strong case for public health and social justice advocates claiming for fairer social and economic policies, as a way to reach the reduction of health inequalities which most governments are putting among their targets.
What we found and what are the implications for policy
Economic recessions, fiscal policies and health. The health impact of the recent Great Recession in Europe depends on the health indicator, country level of social protection, and individual socioeconomic position and gender. Social protection policies appear to be effective in limiting the sensitivity of mortality to macroeconomic fluctuations. Besides, interventions to protect and promote mental health, to prevent suicides, to treat mental disorders and to prevent harmful drinking become especially relevant in times of economic hardship.
Even though recessions may reduce mortality in the short term, those positive effects may be more than compensated by the mortality increasing effect of austerity policies, at least as far as some causes of mortality are concerned.
Generous social protection policies reduce poverty and improve health. Generous unemployment insurance policies reduce material hardship and psychological distress for the unemployed and the employed. Health benefits can arise from increasing unemployment insurance generosity, specifically to ensure that the majority of unemployed individuals receive unemployment benefits; flexible eligibility criteria that include work situations such as seasonal work, reduced hours and self-employment; an adequate income replacement rate that meets the cost of living for a healthy life; short or no waiting periods between job loss and receipt of benefits and provision of benefits for the whole duration of unemployment.
A large proportion of new onset of chronic illness is attributable to unemployment. Policy interventions that maintain employment, and rapidly return the unemployed back into the workforce, can reduce the burden of chronic conditions in European health care systems.
Generous family support policies are predictive of less child poverty. Increased active labour market policies spending is linked to better population health. Opposition efforts to social protection cuts are successful when the target group is politically powerful.
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality. To measure and monitor precarious and informal employment and their health impact, standardised definitions and indicators have to be developed as well as strongly improved surveys and information systems. Employment conditions and quality of employment and their relation with health inequalities differ between and within EU-countries. The growth of precarious employment must be halted, and jobs should become more secure and of better quality in order to protect the health and well-being of workers, and reduce social inequalities in health.
Employment security and the quality of psychosocial working conditions and work-family balance should be improved, also for self-employment and micro-enterprises. Labour market policies such as employment protection legislation, part-time arrangements or workers' safety representatives impact on workers’ health.
Urban planning matters for health equity. Social and functional mix, density, safety and accessibility all matter for health, therefore the way cities manage urban planning makes a difference in the health of residents, especially women and elderly. Policies aiming at equal access to recreational facilities, markets and other core public services may not be enough: deprived neighbourhoods may need more tailored investments for benefiting from the health promoting role of urban density, access to public spaces and facilities, and a vital mix of functions.
As an example, the population health in the more deprived areas could benefit from investments in urban regeneration. Different urban renewal projects have been shown to have a positive impact on self-reported health and the reduction of socioeconomic health inequalities, or to stimulate healthy behaviours, but not to reduce traffic injuries.
Housing policies can reduce health inequalities. A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. In Europe, housing conditions related to fuel poverty are unevenly distributed and affect health. Housing insulation for fuel-poor households can improve health and reduce cold-related mortality. Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, targeting the most affected groups and adapted to their needs.
Public policies that tackle housing instability and their consequences are urgently needed especially in Southern European countries, where people facing housing exclusion experience dramatic levels of mental distress. Access to secure and adequate housing can improve health of these populations.
Gender policies influence gender inequalities in health. Gender inequalities in health are larger in countries with policies less oriented towards gender equity. Policies that support women’s participation in the labour force and decrease their burden of care, as for example increasing public services and support for families and entitlement for fathers, are related to lower levels of gender inequalities in health. Parental leave reserved for both parents with universal coverage and earning replacement, and working time flexibility to balance family demands seem to contribute to equalising gendered time use. Public services and benefits for disabled and dependent people can reduce the burden placed on their family caregivers, improving their health.
Integration policies make a difference on immigrants’ health. Different integration policy models across Europe appear to make a difference on immigrants’ health. Immigrants in "exclusionist" countries, with severe restrictions in access to citizenship and little policies for integration, suffer poorer health, more depression and higher mortality. Therefore, adopting restrictive policies in areas related with immigrants’ integration may have health consequences. Within the healthcare sector, legal barriers in the entitlement to public systems hinder immigrants’ access to necessary care.
Lessons learned on the research process that can inform future studies
Evaluating structural policies is a new methodological challenge. Mixed methods are essential to such evaluation, and we found that a combination of quantitative and qualitative including realist approaches yielded evidence that was strong, rich and relevant.
Quantitative cross-national comparisons provided novel knowledge on the association of broad policy ‘regimes’ with health inequalities, especially in yet less explored fields. Most comparative studies would not have been possible without the many European-wide surveys initiated in the last 10 to 15 years, and we strongly recommend further development of these surveys.
When available, quasi-experimental data (e.g. time-trend or pre-post intervention-control) could yield stronger evidence, although usually referred to specific interventions with small impact as compared to the current magnitude of health inequalities.
Despite several challenges in their application, realist approaches help to address new and vital questions about how policies achieve impacts and under which conditions. Moreover, as the impacts of changing contexts and policies differ at the intersection of different axes of inequality, the intersectionality perspective should be taken into account in the design and evaluation of policies and reinforced in research on health inequalities.
Community and civil society participation in health equity research is a costly and long-term but worthwhile process. Participation of affected populations and frontline professionals adds validity to policy evaluations and research, and the voice of frontline organisations is highly valued by society and can maximise research impact. Face to face contact, respect and gaining the trust are key for the effective involvement of stakeholders in research and in the use of findings.
Beyond scientific dissemination, social media are good channels to increase the reach of politically relevant research. Researchers should make efforts to actively disseminate through emerging social channels their work and knowledge on social and political determinants of health, and funding agencies and research institutions should back these efforts.
(Please find a web version of our conclusions at www.sophie-project.eu/pdf/conclusions.pdf)
Project Context and Objectives:
Health inequalities are unfair and avoidable differences in health between population groups defined socially, economically, demographically or geographically. They are strongly affected by the circumstances in which people are born, grow, live, work and age, and by the policies influencing these circumstances.
SOPHIE has aimed to generate new evidence on the impact of structural policies on health inequalities, and to develop innovative methodologies for the evaluation of these policies in Europe.
Its specific objectives were:
To generate new evidence on how structural policies - macro-economy, welfare state, employment relations, unemployment, built environment and housing policies - impact the determinants of health inequalities by gender, migration status and socio-economic position.
To generate evidence on how gender-oriented and immigration-related policies impact health inequalities, as well as the determinants of these inequalities.
To develop, refine and apply innovative methods for the identification and evaluation of how structural policies impact health inequalities at the European, national and local levels.
To develop, refine and apply innovative methodologies to increase the involvement of affected stakeholders (civil society, deprived social classes and ethnic minorities, women, immigrants) in the identification, design and evaluation of policies to reduce health inequalities.
To disseminate the findings and recommendations on how structural policies reduce health inequalities by implementing strong knowledge translation approaches to affected communities, stakeholders and responsible policymakers.
Project Results:
Economic recessions, fiscal policies and health
Has the Great Recession been bad for health? It depends.
Why is it important? Recessions – by their very definition – have severe adverse economic effects, in terms of increasing unemployment and poverty rates. What appears less clear is what the health effects of recessions have been, and in particular those of the recent recession (the “Great Recession”) that took off in 2008. Knowing what the likely effects of recessions are can usefully inform policy measures to mitigate or prevent potential adverse health effects.
What we did. We assessed the impact of macroeconomic fluctuations (including recessions and booms) on a battery of overall and cause-specific mortality rates for a sample of European Union countries. We examined in particular the effect of the Great Recession. To this end, we carried out a regression analysis, using country-level, annual data on mortality rates, health behaviour proxies, socioeconomic and demographic indicators for 23 European Countries covering the period from 2000 to 2010, taken from WHO and Eurostat databases.
What we found. Overall, during the recent recession, a 1% increase of the standardised unemployment rate has been associated with a statistically significant decrease in all-cause-mortality, cirrhosis- and chronic liver disease-related mortality, motor vehicle accident-related mortality, parasitic infection-related mortality, but an increase in the suicide rate. In general, the effects were more marked in countries with lower levels of social protection, compared to those with higher levels (Figure 1). 1
In other more methodological work we found results of the effect of recession on mortality does differ in critical ways according to the specific methodology applied.2
Detailed country-specific analysis on Spain provided a more complex picture of the health effects resulting from recessions: while we confirmed the counter-intuitive result that a recession, even one that has been as severe as the recent Spanish one, may have improved overall self-reported health, some dietary behaviour was shown to have deteriorated, as well as mental health in men, and some socioeconomic inequalities in health and health behaviour have widened. 3,4
While recessions may have reduced mortality rates, austerity regimes appear to have increased them.
Why is it important? Some have also argued quite vocally that austerity policies are responsible for some deterioration in health care and health outcome indicators. Yet it is not easy to separate the effects of recession from those of austerity, as both often coincide. Again, knowing the health effects is important, as it can help appreciate the full range of costs (and benefits) of austerity policies.
What we did. We assessed the impact of austerity policies, while controlling for the impact of recession, on a set of overall and cause-specific mortality rates, again for a sample of EU countries. In order to measure austerity, we borrow an indicator that has commonly been used in the macroeconomic literature (‘Blanchard Fiscal Index’), including it in our standard regression model as an additional explanatory variable, using data from 23 European countries covering the period 1991-2011.
What we found. Using - for the first time in this literature - a direct measure of austerity policies, we find that across Europe austerity is associated with an increase in all-cause mortality, injury mortality, cardiovascular disease mortality and suicide mortality (Figure 2). However, where there is a mortality increasing effect of austerity, that effect is partly compensated by a mortality decreasing effect of recessions, with the exception of suicides, that appear to receive a double ‘boost’ from both austerity and recessions.
In focus: Economic crises and alcohol consumption: a realist systematic review 5
Economic crises are complex events that affect behavioural patterns (including alcohol consumption) via opposing mechanisms. With this realist systematic review, we aimed to investigate evidence from studies of previous or ongoing crises on which mechanisms play a role among which individuals, in order to understand and predict the potential impact of economic crises on alcohol consumption. We found 16 studies with evidence on two behavioural mechanisms by which economic crises can influence alcohol consumption and alcohol-related health problems. The first mechanism suggests that psychological distress triggered by unemployment and income reductions can increase drinking problems. The second mechanism suggests that due to tighter budget constraints, less money is spent on alcoholic beverages. Across many countries, the psychological distress mechanism was observed mainly in men. The tighter budget constraints mechanism seems to play a role in all population subgroups across all countries covered in the included studies. For other mechanisms (i.e. deterioration in the social situation, fear of losing one's job, and increased non-working time), empirical evidence was scarce or absent, or had small to moderate coverage. This review suggests that among men (but not among women), the net impact of economic crises will be an increase in harmful drinking. This could potentially contribute to growing gender-related health inequalities during a crisis.
Generous social protection policies reduce poverty and improve health
Generous unemployment insurance policies reduce material hardship for the unemployed and psychological distress also for the employed
Why is it important? There is evidence that supports the link between unemployment, poverty and ill health. Limited work has examined the mediating impacts of unemployment insurance on poverty and health, and whether these associations between countries vary in relation to the different generosity levels of their unemployment insurance systems.
What we did. We undertook a realist review to examine how and why unemployment insurance policies impact poverty and health in different welfare states.1,2
What we found. The generosity of unemployment insurance eligibility, duration and wage replacement levels can reduce poverty, material hardship and psychological distress among the unemployed. It is also related with the psychological distress among the employed population. Generous unemployment insurance policies can moderate harmful consequences of unemployment.3,4
In focus. Generous family support policies are predictive of less child poverty
We performed a realist scoping review of the literature and we found that generous family support policies (FSP) reduce child poverty because they support and increase the freedom of parents to ensure their children are receiving basic opportunities. Family support policies include job-protected leave that enables new parents to remain attached to paid employment after childbirth (i.e parents have the legal right to keep their jobs), public childcare that offers affordable options for parents (i.e. children receive inexpensive or subsidized care during work hours), paid leave that replaces lost incomes (i.e. parents receive a ratio of benefits relative to their gross earning), and cash transfers that offset the material costs of raising children (i.e. parents receive tax-free family payments or allowances). Moreover, when FSP are comprehensive, universal (i.e. available for everyone) and packaged as ‘dual-earner policies’ (i.e. available for both parents), child poverty is the lowest. 5
Health improves as states increase spending on active labour market policies
Why is it important? The primary goal of active labour market policies (ALMPs) is to increase the employment opportunities for job seekers and to improve matching between jobs and workers. In so doing ALMPs can reduce unemployment and benefit dependency, and together with passive labour market policies (mainly unemployment insurance), they act as important forms of social protection for workers. There is little evidence on the impact of ALMPs on health.
What we did. Using a pooled cross-sectional analysis of 20 European nations and 5 welfare regimes, we examined the association between active and passive labour market policy expenditures and self-rated health, adjusting for other individual and macro-level factors.
What we found. Increased spending on ALMPs was associated with better self-rated health (significantly among men).6
In focus. Unemployment, a major cause of chronic illness
Using a multilevel, longitudinal analysis across the EU, we examined the effects of short-term and long-term unemployment, and unemployment insurance generosity, on health. We found that unemployment insurance system generosity was not associated with health in the total sample, although, the longer individuals were unemployed the worse their health. In particular, almost one-fifth of new onset chronic conditions (18%) were attributable to unemployment pattern, more than sex and educational attainment (see Figure 1). 7
Opposition efforts to social protection cuts are successful when the target group is politically powerful
Why is it important? Social protection policies are critical in providing a safety net for citizens. Although during economic crises, many countries apply austerity measures in hope of restoring the economy. This threat of cuts to social protection policies can have a damaging effect on the health and well-being of citizens.
What we did. To understand why and how policies resist austerity, we conducted a set of theory-driven explanatory case studies, interviewing politicians, policymakers and civil society members.
What we found. We found strong evidence that opposition to cuts to fuel poverty programmes and policies, during times of austerity, is successful when the target group is politically powerful (i.e. electoral power). For example, the Winter Fuel Payment (WFP) in England is the only fuel poverty programme or policy that has been maintained during a time of widespread austerity (after 2010) because the elderly (the target recipients) have high voting turnout, and are a core constituency of the incumbent conservative party. Our research shows that even despite the fact that approximately 80% of the elderly who receive the WFP do not actually live in fuel poverty, they all still receive the payment. The conservative party has maintained the WFP to the elderly, whether they are fuel poor or not, “because by and large they vote”. 8
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality
Surveys are useful for monitoring employment conditions and their impact on work-related health (inequalities) but they must be strongly improved.
Why is it important? In contemporary labour markets, where the old standard stable, full time employment is decreasing, the quality of employment involves a serious threat to workers’ health. Low quality employment and resulting situations of employment precariousness, as well as informal employment, are not well conceptualised and measured leading to unsatisfactory estimations of their impact on health. 1
What we did. We defined new multidimensional concepts for measuring employment quality, employment precariousness and informal employment and their health impact in contemporary European labour markets.2 Based on these concepts, a protocol for determining proxy indicators of employment quality3 and precarious employment4,5 was applied to the data from different surveys. We also performed scoping reviews of informal employment to identify the best definition and measure for health inequalities studies. 6,7
What we found. Factors determining the quality of employment in Europe can be summarised in five different types of jobs regarding their employment quality3: SER-like (similar to the ideal standard employment relation), Instrumental (relatively stable but with few benefits), Portfolio (highly skilled but rather flexible), Precarious unsustainable (with adverse employment conditions and relations) and Precarious intensive (with the most adverse scores, especially regarding on work intensity and high flexibility) (Figure 1). Precarious employment is far broader than simple dichotomies between standard and non-standard employment – and constitutes an important social determinant of health in contemporary labour markets.2 Precarious and informal employment definitions differ across countries.3,4,6 Precarious employment should be studied using a common definition with a multidimensional perspective;2 informal employment should be conceptualised and measured with reference to the level of informality6 and social protection7.
In focus. Employment precariousness in Catalonia
To study the prevalence of precarious employment in Catalonia (Spain), measured with a multidimensional scale, and its association with mental and self-rated health, we identified proxy indicators using data from the II Catalan Working Conditions Survey (2010).We found that the prevalence of precarious employment in Catalonia was high (42.6%) and that it was higher in women (51.4%), youth (86.6%), immigrants (67%), and manual (48%) and less educated workers (51.3%). There was a positive gradient (3 times higher) in the association between precarious employment and poor mental (Figure 3) and self-rated health. Our conclusion is that precarious employment is associated with poor health in the working population. Working conditions surveys should include questions on multidimensional precarious employment and health indicators, which would allow monitoring and subsequent analyses of health inequalities.5
Employment conditions and quality of employment and their relation with health inequalities differ between and within EU-countries.
Why is it important? Working and employment conditions under which people work constitute one of the most powerful social determinants of health during adult life. The contemporary world of work entails many old and more recent challenges for health and well-being.
What we did. Using different European surveys (European Social Survey (ESS) and European Working Conditions Survey (EWCS)), we analysed quality of employment and its relation with health. 8,9,10 We also analysed precarious employment and its relation with health using Employment Precariousness Scale (EPRES) for Spain11and informal employment using data available from EWCS12.
What we found. The quality of employment clearly differs between EU-countries, leading to generally high quality employment in the Nordic countries and high rates of precarious employment in Southern-European and Eastern-European countries and it is clearly related to self-perceived job satisfaction, general health (Figure 2) and mental health8. Country differences related to quality of employment are also affecting class and gender-based socio-economic inequalities in (mental) health9,10, making employment quality an important determinant of health inequalities. The prevalence of precarious employment has increased between 2005 and 2010 (48% vs. 51%), being higher among women, manual workers, immigrants and workers with low education attainment and with temporary contracts. Precariousness also impacts mental health5 (Figure 3) even among permanent workers11.
In focus. Self-employed persons in Sweden
Self-employed persons and their enterprises are important to the economy for their contribution to economic development. However, an understanding of the relationship between the psychosocial working conditions, the work-life balance and outcomes, such as health and wellbeing among the self-employed and micro-enterprises, is limited. Data from the European Social Survey show that men and women who are self-employed experience a lower level of work-life balance compared to other groups of employees. Self-employment is positively related to subjective well-being, but differences arise between different groups of the self-employed, with those who are self-employed with employees reporting a higher level of life satisfaction than the self-employed without employees. The analyses also point to different patterns for female and male self-employment without employees and for immigrant groups compared to natives. Data about Swedish self-employed persons also show that all-cause mortality is high in some sectors like Manufacturing and Mining or Trade and Communication in working life and that there are 8-16% higher mortality risks among sole-proprietorship, compared to limited partnership13,14,15.
Labour market policies impact on workers’ health
Why is it important? Labour legislation plays a critically important role in providing a framework for fair and efficient employment relations that eventually deliver fair and decent employment.
What we did. We performed a realist review of how and why employment protection legislation impacts temporary employment16 and a systematic review to summarize the scientific evidence about the relationship between part-time employment (PTE), working and employment conditions and health status and the potential reasons of the heterogeneous results.17 We also undertook case studies to analyze specific employment-policies and interventions in different countries.18-22
What we found. Labour market, social and employment policies have led to the precarization of the European labour market creating worse working and employment conditions. Employment protection legislation was particularly under attack, before the outbreak of the economic and financial crisis increasing inequalities and insecurity of workers and also precarious employment.16 The relationship between PTE, working and employment conditions and health status depends, considerably, on welfare state types, gender, PTE measurement and their voluntary or forced nature.17
In focus. The Belgian Service Voucher System, health and health inequalities.
We have investigated the quality of work in the service voucher system. This study has shown that policy makers have paid substantial attention to the employment conditions (training, working hours, contract duration) in the system, but that debates on the other characteristics of the quality of work are scarce. Several changes have been made to improve the stability of the employment contracts, but some employers apply illegal practices to get around regulation. Given the vulnerability of some service voucher employees, more wage transparency and payments toward social security benefits are needed. This case study has shown that inequalities exist between service voucher employees, related to the Social Paritary committee, between for-profit and not-for-profit organizations, between native workers and immigrant workers.18
In focus. Worker participation in occupational health and preventive action.
Workplace representative participation contributes to the preservation of workers' health. However, some groups of workers may not benefit from their representatives’ action due to their employment conditions. We analysed the impact of labour market precarization on the relationship between workers and their representatives in occupational health,19,20 as well as its consequences on preventive action drawing on data from a Spanish National Working Conditions Survey (2011)21. Workers reporting to have representatives were protected by greater preventive action at their workplaces than workers reporting not to have representatives or unaware of their existence.
Urban planning matters for health
Social and functional mix, density and accessibility matter for mortality and mental health
Why is important. People living in urban setting constitute the larger and increasing proportion of the European population. Urban planning, comprising residential areas, public spaces, services and infrastructures, is acknowledged to be an important policy area for promoting wellbeing inside cities, however its health equity impact is still barely evaluated.
What we did. In few European metropolitan areas we compared with a population cohort approach mortality (Torino, Barcelona, Stockholm, Helsinki)1 and antidepressant drug consumption (Torino)2 of people living in urban areas that were exposed to a different mix of social or physical characteristics as a result of urban structure. We used data from Longitudinal Studies, combined with census data, and only for Torino we collected and mapped data on urban transformation in the last 30 years.
The urban planning choices that stay behind such differences are intended to drive the main aspects of the built and social environment that are potential determinants of health impacts according to several literature reviews. 3,4,5,6 The relative contribution of these determinants of the social and built environment to the trend of inequalities in mortality in an urban setting (Torino) has been estimated compared to the contribution of the individual and social determinants.7,8
What we found. As expected, the individual indicators of social disadvantage show the strongest contribution to inequalities in mortality8 and mental health2, but the deprivation of the neighbourhood where we live also plays a significant and independent role in the risk of premature mortality 8.
Part of this contextual effect may be due to segregation of population of lower socioecononomic position to disadvantaged neighbourhoods, as unintended consequence of urban transformations and interventions. 1
On the other side, the study in Torino 2 suggests that part of this contextual effect may be due to the built environment itself: in fact minor depressive disorders, a health outcome more sensitive to short term impact, seem to benefit from higher urban density and better accessibility by public transport; women and elderly are the most exposed to neighbourhood characteristics, reporting more significant health impacts. However these features of urban structure protecting mental health (accessibility and density) are evenly distributed across social groups in the city and do not contribute to health inequalities, at least in the case of Torino.
We found that only few studies in Europe tried to assess health inequalities linked to built environment, and that results are highly influenced by the local context, making it difficult to generalize conclusions.5 However local studies maintain particularistic importance for informing local decision making with local evidence.
Urban renewal: positive impact on self-reported health, no impact on road safety
Why is important. In the last decades interventions of urban regeneration have been undertaken in most metropolitan areas for improving the built and social environment of the most deprived areas or dismissed industrial areas, and for creating new transport facilities and infrastructures. The impacts on health and equity of such interventions are not given for granted and deserve attention.
What we did. In a first case study the effects of a large scale urban renewal project (Llei de Barris), combining actions on the built and social environment, on self-rated health and health inequalities in Barcelona have been studied through a quasi-experimental study.9 The case study was complemented by collecting residents’ perceptions on changes in their neighbourhoods with Concept Mapping10 and by using a theory-driven realist approach to explore the complex causal pathways between urban renewal and health inequality 11. A second case study addressed the safety impact of an infrastructural intervention: road traffic injuries trend in the catchment area of the third segment of new subway in Torino has been compared before and after the new metro line opening, using a control area in the same city. 12
What we found. In Barcelona, residents perceived the majority of implemented renewal interventions as having positive and important effects on their wellbeing.10 After renewal, self-rated health improved in the intervened neighbourhoods, most notably among manual social class residents, while no changes were seen in the comparison neighbourhoods (Figure 2). 9
Conversely, in Torino, where we measured registered accidents and not a self-reported measure, the new metro line intervention did not reveal significant reduction in the frequency of road injuries in the catchment area. 6
In focus. Effects of a new metro line in Turin
We assessed the impacts of the new metro line in Torino: contrary to expectations based on the literature, we found that no appreciable reduction in road traffic injuries took place; also gentrification effects (increase in real estate values, displacement of disadvantaged residents) were not spread along the whole metro line, but concentrated in few areas. The particular urban structure of the area, where the metro line is running along the railway line, which also constitutes a barrier towards one side of the city, and the distribution of important facilities as interchange parks, university, shopping mall, is able to strongly interact with the envisaged effects of urban interventions.6
This demonstrates that there are more influential elements than an efficient underground public transport able to generate impacts at urban level. The most important finding however is that an intervention can cause different effects according to the local context and characteristics of the area: urban interventions should therefore be accurately studied, and a case-by-case impact assessment should be performed every time.
Urban renewal can stimulate healthy behaviours
Why is important. Healthy behaviours that are usually socially patterned may be influenced by many aspects of the social and built environment. Physical activity in adults is expected to be facilitated by creation and maintenance of safe environments by urban planning. At the same time built environment and neighbourhood quality may play an important role in teenagers behaviours, especially in relation to substance and alcohol abuse.
What we did. A series of studies in the Netherlands were looking at how safe neighbourhoods could promote physical activity in the general adult population: a quasi-experimental evaluation of the Dutch District Approach tried to assess the impact of area-based initiatives on physical activity trends and safety indicators in deprived areas,13-17 and a companion realist review uncovered how area-based initiatives may stimulate leisure-time walking among adults in deprived areas.18 Another study focused on health behaviours of Prague teenagers, that are at the top of health risk behaviour around Europe, collecting data on characteristics of home and school built environment, neighbourhood quality, and on the prevalence of health risk behaviours by means of a survey.19
What we found. In the Dutch quasi-experiment, safe neighbourhoods promote walking in the general adult population, especially among those living in deprived areas, primarily by stimulating them to walk in leisure time; realist review explained that urban renewal stimulates residents to walk by providing safer, more relaxing, and more convenient environments to walk through. In the Czech cross-sectional study adolescents health risk behaviours seem not to be related to home neighbourhood environment, but rather to the school environment, especially in its outdoor features.
Housing policies can reduce health inequalities
In Europe, housing conditions related to fuel poverty are unevenly distributed and affect health
Why is it important? A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. Access to adequate housing conditions is determined by the interaction between the housing system and the welfare state. A country’s housing system is in turn the result of the interaction between the housing market and housing policies developed over time (Figure 1).1
Figure 1. Conceptual framework on housing systems, housing conditions and health equity.
One of the important aspects of housing related to health, mainly during the economic recession, is the presence and increase of fuel poverty,defined as the difficulty of keeping a house at a comfortable temperature and to meet its energy needs at an affordable cost. Major revisions have compiled abundant evidence on the association between fuel poverty, and its derived thermal discomfort and humidity, and cardiovascular and respiratory diseases, depression, and anxiety. Moreover, a significant percentage of excess winter mortality may be related to fuel poverty.2
What we did.Using the 2012 European Union Statistics on income and living conditions (EU-SILC), we obtained for 29 European countries and for the 5 welfare state regimes in which they are classified (social democratic, corporatist, liberal, southern and transition) the prevalence of poor housing conditions related with fuel poverty (dampness, house not adequately warm, arrears on utility bills) and their association with self-rated health, among population aged 16 or over in the two lower equalised income quintiles. For the same countries, we computed the Excess Winter Deaths Index (EWDI) for 2011-12.3
What we found. In all countries, poor housing conditions related with fuel poverty are associated with poor health, even adjusting for material deprivation. These conditions are poorer and EWDI higher in transition countries and in southern European countries mainly due to the poor quality of the housing stock, rises in fuel prices,and low expenditure on housing policy, particularly in instruments such as housing benefits or fuel benefits.3 This situation has worsened in the countries most affected by the global financial crisis such as Greece or Spain.
Housing insulation for fuel-poor households can improve health
Why is it important? Energy efficiency interventions, such as façade retrofitting, can address fuel poverty from a structural and long-term perspective. Despite evidence of the health benefits of insulation, little is known about the political and social contexts contributing to social inequalities in receiving and benefitting from it.2
What we did.We used a realist review methodology to better understand the mechanisms that explain how and why variations in receiving façade retrofitting interventions and in their impact on health determinants occur across different social groups. We reviewed 124 articles considering four stages of implementation: public policy approach; policy; intervention; impact on health determinants.2
What we found. Social groups suffering most from fuel poverty such as low-income, renters or elderly people, experience more barriers for undertaking a building retrofitting. This is due to mechanisms such as the inability to afford initial costs, landlords' lack of incentive to improve energy efficiency, or even in case of public intervention, insufficient attention to residents' needs or preferences. Energy efficiency policies that do not tackle these factors may exacerbate these inequalities.2
In focus. Façade insulation in social housing and cold related mortality in Barcelona
The objective of this study was to evaluate the impact on the association between cold outdoor temperatures and mortality of energy efficiency façade retrofitting of 310 poorly insulated social housing blocks in the city of Barcelona, occurred between 1986 and 2012. The design of the study was a time stratified case cross-over analysis. The impacts of the interventions were different between men and women. Women living in a non-insulated block had a higher risk of death when exposed to extremely cold temperatures on the same day of death and the day before; but these associations were lost for women living in an insulated block (Figure 2). Associations were stronger in women aged 70-79 and with no education. In men, insulation increased the risks of death 14-16 days after an extremely cold temperature day. While façade retrofitting has significantly reduced the risk of cold-related mortality in women, possible negative impacts in men should be studied. 4
Access to secure and adequate housing can improve health
Why is it important? A common feature of housing systems in Europe is the increase in homeownership in most countries, with rising levels of mortgage debt levels. With the onset of the financial and economic crisis, in countries like Spain with little social housing, arrears, evictions and substandard housing arrangements have appeared as a major problem. This may have had an effect on people’s health. Policies to provide affordable housing can improve socioeconomic conditions and in turn health.
What we did. In Spain, Caritas is one of the institutions focused on helping people with housing problems. We aimed to evaluate, with a longitudinal study, the effect of relocation to a new house through social programs of Caritas on health determinants and health outcomes in the Barcelona area. The sample consisted of adults from families in substandard housing in need of housing relocation, or unable to afford their mortgage or rent. They answered a questionnaire interview in 2012 and again one year later.5,6
What we found. The baseline physical and mental health status of Caritas users with housing problems was much worse than that of the general population.5 Relocated people experienced substantial improvements in housing habitability and affordability. They also improved in various health indicators, although they did it in the same way as people not relocated, some of whom also had improved their housing and socioeconomic conditions. Mental health improved more in those who experienced relief in their precarious socioeconomic situation and improvements in housing conditions (Figure 3).6
In focus. Evictions and health: people affected by mortgage in Catalonia
Since the starting of the economic recession, Spain presents very high rates of foreclosures and evictions. In this situation, civil society has self-organized, being the Affected by Mortgage Platform (PAH in Spanish) one of the most important related movements. A self-administered online questionnaire was completed by 905 adults belonging to the PAH and living in Catalonia. We found an extremelyhigh prevalence of poor mental health among PAH participants (87%), much higher than the general population of Catalonia (13% in the last health survey). Poor mental health was significantly higher already in the period of non-payment compared with those who were up-to-date with the payment while self-rated health status was poorer in later steps of the process, such as post-eviction.7
Gender equality policies influence gender inequalities in health
Why is it important? In most high-income countries women have poorer health than men even if they live longer. Policies that promote equality between men and women can partly bridge the gap among genders.
What we did. We performed a systematic review showing initial evidence that policies that promote gender equity reduce gender inequalities and improve women’s health.1 Thereafter, we classified European countries according to their family policy model (Figure 1) and carried out 3 studies that compared men and women’s self-perceived health2, wage-earner men and women’s mental health3 and the relationship between employment and family burden and self-rated and mental health4 in the different family policy models.
Figure 1. Gender inequalities in self-rated health according to family policy model 1
What we found. In traditional (Southern and Central) and contradictory countries women are more likely to report poorer health than men. This is particularly the case for Southern countries (Figure 1).2 Among wage earners, and across different social classes, gender inequalities in mental health are more widespread and pronounced in market-oriented countries than in other typologies.3 The burden of combining employment and family demands seems especially harmful for the self-rated and mental health of women in traditional countries and men in market oriented countries.4
In focus. Parental leave and gendered time use in Sweden and Spain. Time allocation is a highly gendered process and division of work is an important factor in gender equality. Studies have found that an unequal division of work is related to low well-being especially among women. By using Multinational Time Use Study data from Sweden and Spain in 1990, 2000 and 2010, we observed that changes in leave policies introducing or increasing exclusive paternal leave were followed by reductions in inequality in time use between mothers and fathers. Our conclusion is that family policies that support gender equality through earning replacement, parental leave reserved for both parents with universal coverage, and working time flexibility to balance family demands contribute to equalising gendered time use. 5
In focus. Lone mothers’ health in Spain. Lone mothers are a vulnerable group at greater risk of poverty and unemployment even in rich countries. We analysed two Spanish National Health Surveys, 2003 and 2011, and found that lone mothers presented poorer self-rated health, mental health and health-related behaviours than couple mothers. Manual class lone mothers were particularly disadvantaged. Inequalities between lone and couple mothers did not change along the period. In a traditional family model like Spain, with insufficient family support policies for mothers, socio-economic assets are key to determine access to resources producing health inequalities. This could particularly affect Spanish lone mothers.6
Public services for disabled people can improve the health of family caregivers
Why is it important? The adverse effects of family caregiving on physical and mental health are well documented. In Spain, this burden is concentrated among women, mostly of low socio-economic position. The Dependence Act, passed in 2006, represented an advance in social rights by declaring the universal nature of social services and recognising the subjective right of dependent persons to receive an economic contribution to family caregivers and a set of services at home or in care centres. Although its budget implementation has been limited, especially after austerity cuts in 2012.
What we did. Using data from the Spanish National Health Survey 2006 and 2012, we compared the mental health and self-rated general health of cohabitants of a disabled person who were responsible of their care, and non-caregivers.7 We used Concept Mapping to gather views of informal caregivers and primary healthcare professionals on how the Act had influenced the caregivers' quality of life.8
What we found. Between 2006 and 2012, in both sexes the health of family caregivers has improved more than that of non-caregivers (Figure 2).7 Concept mapping showed that the Act brought for caregivers the possibility of sharing the burden of care, reducing its physical, mental and social consequences, while at the same time being able to maintain responsibility on the dependent person. Nonetheless, implementation problems, delays, insufficient budget and austerity cuts in services and benefits were also affecting caregivers negatively. 8
In focus. How to resist austerity: the case of the Gender Budgeting strategy in Andalusia. As a political response to the current economic crisis, important budget cuts in public policies have been implemented as well as the downgrading of gender equality policies. An example of policy that has resisted austerity is the gender budgeting strategy in Andalusia. To understand why and how, we conducted a theory-driven explanatory case study. We interviewed politicians, policymakers and civil society members. The main reasons for the resilience of the strategy include a strong political commitment with a solid female leadership supported by a strong left-wing government, as well as several mechanisms triggered by the previous context of institutionalization of the strategy and the facility provided by its low maintenance cost.9
The intersectionality perspective is important in health equity research and policy evaluation
Why is it important? Socio-economic position, gender, ethnicity or immigrant background are axes of social inequality that interact among each other in creating health inequalities. Thus the design of policies to tackle health inequalities and their evaluation need to take into account all these dimensions, as well as their intersections.
What we did. We have developed a quick guide for incorporating intersectionality in evaluation of policy impacts on health equity, including practical examples based on the experience in the project.10 Whenever possible, we have stratified our analyses by sex, socio-economic position, immigrant background and/or age.
What we found. The impacts of changing contexts and policies differ at the intersection of different axes of inequality. For example, through the economic crisis in Spain, poor mental health increased in middle-aged and manual social class men, but not in other groups,10 and in immigrant more than native men.11 Immigrant background and gender intersect and reinforce one another to produce inequalities in the labour market in Europe, such as in the quality of work, health and safety risk or workplace discrimination.12,13 A qualitative study among domestics working in the service voucher system in Belgium revealed that immigrant women are particularly vulnerable for a poor work quality and work-related health and safety risks. Their negotiation power with clients is hampered by their limited labour market opportunities or problems related to their residence permit.14
Integration policies matter for immigrants’ health
Immigrants in “exclusionist” countries suffer poorer health
Why is it important? Immigrants constitute an increasing proportion of the European population. The debate on policies to control and integrate immigration has been high on the agenda for many years, but very little is known on their health impacts.
What we did. We compared health inequalities between natives and immigrants across European countries that apply different integration policy models (Figure 1):
• The “inclusive” model, characterised by easy acquisition of citizenship and tolerance of cultural differences;
• The “assimilation” model, relatively open on nationality, but restrictive on residence, access to labour market and cultural manifestations in public;
• The “differential exclusionist” or “guest worker” model, basing citizenship on ancestry, characterised by low social and political tolerance and little active integration policies.1
We studied self-rated health using survey data from the 2011 European Union Statistics on Income and Living Conditions, comparing individuals born in the same country of residence or outside the EU and having resided 10 years or more in the country.2 We analysed mortality data of the Netherlands (inclusive), France (assimilationist) and Denmark (exclusionist), comparing people born in Turkey or in Morocco (origins well represented in the three countries) with people born in the same country of residence.3 Using the European Social Survey 2012, we compared depressive symptoms in individuals born in the same country of residence or in less economically developed countries.4
What we found. Inequalities in living conditions and self-rated health between immigrants and natives were highest in exclusionist countries (Figure 2).2 Immigrants also had the highest mortality in Denmark compared to their compatriots in the Netherlands and France (Figure 3).3 Inequalities in depressive symptoms were also largest in exclusionist countries followed by assimilationist countries, and particularly in countries poorly ranked in integration policy comparisons such as Switzerland and Denmark.4
In focus: Discrimination and health among persons with immigrant background in Europe
We used the European Social Survey of 2012 to study the association of perceived membership to a discriminated group and three health indicators among people born abroad or with both parents born abroad (excluding IMF advanced countries), taking into account gender, generation and country integration policy. Perceived membership to a discriminated group was associated with poorer health outcomes, mainly depression, only for first-generation immigrants, and among those, especially in assimilationist countries.5
In focus. Healthcare exclusion in Czechia
In Czechia, regular immigrants without permanent residence are not entitled to public health insurance and should purchase a commercial insurance. With this system, we found that the real access to health services of these immigrants is much lower than that of Czechs and permanent residents;6 and even among these permanent immigrants, many lack knowledge of their rights and remain out of the public system.7
The assessment of health equity impact of structural policies: evaluation of research methods
Evaluating structural policies is a new methodological challenge
The “inverse evidence law” states that the more a policy could impact on population health, the harder it is to convincingly demonstrate this impact. In public health, there is considerable evidence about the health impact of interventions aimed at modifying behavioural factors such as smoking and drinking. Much less is known about policies addressing the wider economic, social and physical environments in which people live (called here ‘structural policies’), despite the intuition of a much larger impact. The challenge of SOPHIE has been to advance in the generation of such evidence.
Approaches aligned with the principles of evidence-based medicine, including before-and-after measurements and control groups, are sometimes applicable in practice to structural policies, even though the researcher does not hold control over the policy execution. In this, we should recognise that most structural policies are inherently complex. Their population health impact may strongly depend on the ways in which they are implemented, the populations that they target, and the wider context. Then, it is problematic to just summarise the evaluation in terms of a simple ‘yes/no effect’. Alternative designs are needed that are able to generate more nuanced insights, and to draw careful lessons that may be transferable to other populations.
Mixed methods are essential to the evaluation of structural policies
In the SOPHIE project, various approaches were used to assess and to understand the impact of structural policies on population health and on health inequalities. It was found that a combination of quantitative and qualitative or realist approaches was essential to fully assess the impact of structural policies. Mixed methods yielded evidence that was strong, rich and relevant.
Quantitative approaches were applied mostly with the aim to assess whether a structural policy has had a demonstrable impact on health-related outcomes, how large this effect appeared to be, and whether this impact differed according to socioeconomic position. Some studies made comparisons between places, such as countries, regions, or small districts, relating variations in structural policies to variation in health outcomes. Other studies made comparisons over time, such as comparisons before/after the introduction of a new policy measure. In time series analyses, more detailed data of trends over time were used to assess whether the introduction of a policy was followed – immediately or gradually – by a change in health outcomes. Finally, some studies applied ‘quasi-experimental’ approaches that combined the geographic and time dimensions, for example, by applying the before-after design to both the population exposed to the intervention and to a control population (e.g. those living in another neighbourhood).
In addition to these quantitative approaches, the SOPHIE project applied in-depth analyses that included qualitative research methods, to identify the mechanisms through which a structural policy could influence population health. Several methods have been used, such as concept mapping and multiple case studies. In particular, we explored the feasibility and informative value of ‘realist’ approaches, including realist reviews and realist evaluations, especially aimed to test expectations regarding how a structural policy could affect population health, and under which condition, i.e. when/where, the same policy would set in motion specific mechanisms.
Quantitative comparative approaches yielded novel knowledge
Most studies performing quantitative comparisons over time and/or place yielded novel evidence on the impact of structural policies on the health of disadvantaged groups such as manual workers, women or ethnic minorities. Some common challenges had to be addressed. In the SOPHIE project, much experience was gained from cross-national comparisons. It was found that the strength of evidence depended on various conditions.
1. The study had to be able to control for confounding by national factors, such as measures of national income. A particular challenge may be to control for other policies that were developed in parallel with the structural policies of interest.
2. The study had to maximise the number of countries studied, which, for Europe, is limited to less than about 30. In particular, the study had to find ways to apply statistical control for several confounders even with such a limited number of countries was limited (e.g. multi-level analysis with control for individual-level confounders).
3. Problems in the comparability of the information on the structural policies of interest may induce systematic or random measurement bias, and affect study outcomes. Using comparable though simplistic indicators may be a solution, but may at the same time cause problems of measurement validity.
Many SOPHIE studies found ways to address these challenges in their particular case, depending on the topic of interest and the data that were available.
The application of time trend analysis, rather than cross-sectional comparisons, yielded stronger evidence on the impact of structural policies. The experience of SOPHIE studies is that stronger evidence could be obtained if:
1. The structural policies of interest rapidly changed over time. Sudden policy changes generate ‘natural policy experiments’ that can be assessed in a quasi-experimental design. In contrast, policy changes that are gradually implemented over a period (say 5 to 10 years) are generally harder to evaluate for their population health impact.
2. The available data sources are continuous (say, monthly, yearly or two-yearly) instead of covering only a few points in time. Continuous time series increase the possibility to accurately follow trends in health-related outcomes after a policy change, and thus to assess lagged dose-response relationships.
3. No major developments occur in other fields. Confounding may occur by concurring changes in other policy areas. Such problems can be solved with multi-country studies that compare ‘experiment’ to ‘control’ countries which differ especially with regards to the policy of interest.
Realist approaches help to address new and vital questions
When applied in isolation, the quantitative approaches may results in simple ‘yes/no’ verdicts regarding the impact of structural policies on health inequalities. ‘Realist’ approaches have been used in the project to address how questions, allowing SOPHIE researchers to disentangle the mechanisms through which structural policies could affect the health of people. By doing this, we were able to formulate policy conclusions that were more nuanced and aligned with the reality of people’s lives. Such detailed knowledge could also help us to formulate lessons that take into account the context, i.e. under which conditions a structural policy would have the promised impact.
The experience of SOPHIE researchers is that, to fully seize the potential of realist approaches, several challenges have to be faced:
1. The strength of the evidence strongly depends on the quality and richness of the information that could be obtained from primary sources or published studies. For example, in a field dominated by quantitative studies, there may be little qualitative information on the mechanisms of interest, and a ‘realist’ synthesis may not have sufficient material to test and refine initial expectations.
2. A clear and efficient working protocol must be developed. Published studies using ‘realist’ approaches greatly varied in the ways in which the studies are executed and results are presented. Further standardisation (see e.g. www.ramesesproject.org) is expected to increase the efficiency, quality and transparency of each individual study.
3. On another level, scientists using ‘realist’ approaches should find ways to deal with the current publication pressure, as these methods can be more time-consuming than quantitative studies and harder to get into most high-impact scientific journals. In similar ways, because of the lack of simple answers, it may be more difficult to disseminate the results to policy-makers or professionals, especially those trained only in positivist, quantitative science.
Yet, ‘realist’ approaches are an indispensible complement to ‘black box’ studies that only aim to demonstrate and quantify the impact of a structural policy. These approaches need to be further developed, applied and promoted in public health.
Implications for policy-oriented research
In future work, stronger evidence on the health equity impact of structural policies could be obtained by further application of the quasi-experimental design, i.e. a pre-post, intervention-control design. As a general rule, the strength of evidence increases with (1) a larger number of control and interventions areas, (2) a more detailed measurement of intervention exposure and of confounders, and (3) the inclusion of more subsequent years of observation.
Qualitative or ‘realist’ approaches are indispensible to understand and predict the impact of structural policies. They can best applied together with a primary, prospective collection of data, such that expectations regarding “mechanisms of change” can be assessed with rigour and detail. Moreover, in the ideal case, these approached are complemented with quantitative comparative approaches that aim to test and quantify the expected health impacts, to simultaneously assess “whether, how much” and “how, when” a structural policy would reduce inequalities in health.
Broad structural policies and ‘regimes’ may be most relevant for the reduction of health inequalities. However, they may be hard to assess for their precise impact, while the variety of mechanisms and context-dependencies may be overwhelming. On the other side, specific structural policies of interest may be assessed with greater detail and rigour, but the demonstrated impact may turn out to be deceptively small as compared to the current magnitude of health inequalities. Further research shall have to find a balance each time between the brush and the tweezers.
In the SOPHIE project, we learned that the key challenge is to get stronger evidence impact of such policies on people’s health. If such an impact could be assessed for a population at large, it is possible in principle to also assess this impact for subpopulations stratified according to socioeconomic position or other axes of inequality, given a sufficient statistical power in the available data.
Novel statistical approaches such as Propensity Score Matching and Difference-in-Difference methods did not appear to offer a satisfactory solution to the key challenges. Often, the key issue was about observation and measurement. In SOPHIE, most comparative studies would not have been possible without the many European-wide surveys that were initiated in the last 10 to 15 years. We strongly recommend further development of these international surveys in the next decade.
Maximising the social impact of health equity research
Community and civil society participation, a costly but worthwhile process
Why is it important? Stakeholders’ involvement in research projects plays a key role in ensuring exploitation of the project results with the aim to tackle health inequalities. It may contribute to the creation of a bridge between stakeholders’ needs and research outputs, hopefully leading to more socially relevant research. However, only few projects and studies make efforts to engage with non-academic stakeholders. Socially disadvantaged groups may be especially hard-to-reach when traditional research methods are used, resulting in under-researched topics and/or data and conclusions of questionable validity.
What we did. Focusing on community-based participatory research (CBPR), one of the most promoted approaches to involve affected communities at all stages of research, we performed a scoping review of 38 full-text articles on CBPR studies addressing in particular ethnic minorities and migrants, aiming to systematize current operationalization of the CBPR concept by researchers, especially of its expected causal roles.1
As regards knowledge transfer, we also conducted an applied ethnography (detailed case study) within the largest state-backed health equity project of its kind focused on segregated Roma communities called Healthy Communities.2
To move from theory to practice, we also drew lessons from different degrees of community partnership experimented in the project, such as Caritas Barcelona participation in the SOPHIE consortium and in housing research. We elaborated a report related to experiences on involvement of different stakeholders into the research process.3
What we found. In the scoping review, we found that CBPR is practically not being used by researchers explicitly as such for research on migrants and ethnic minorities in Europe. Even beyond Europe, that its expected causal roles are being operationalized by the researchers in a rather unsystematic manner. Based on overlaps in the researchers’ impressions, however, several causal mechanisms can be postulated through which particular CBPR features, e.g. sensitive pre-assessment of cultural and social norms, seem to facilitate communities' involvement in research in the area of migrant and ethnic minority health.1
Results of case study of Healthy Communities showed that the community participation concept was not translated into the organizational level as intended within the expert discourses. Despite this conceptual weakness, project appeared successful in fostering intended changes in the target population’s health-related circumstances exactly thanks to its participative features (see box).
Box 1. Mediating health for segregated Roma in Slovakia: An ethnographic case study
Health-mediation programs represent pivotal state-backed health-equity policies addressing segregated Roma communities in Central and Eastern Europe. The Slovak Healthy Communities (HC) program, running for over 10 years, predominantly employing segregated Roma, and now serving nationally in nearly 200 communities under direct supervision of Ministry of Health, counts among the most advanced of these initiatives.
In our applied ethnographic study of the HC program we relied on analyses of documentation, long-term participant observations, and semi-structured interviewing across all organizational levels of the program. We found the program to be rather out-dated and flat on paper conceptually: it set out to emphasize but the targeted population’s health-related behaviour and responsibility and to intervene but through edification and temporary assistance with healthcare access. Nevertheless, thanks to an implicit standard of pragmatic flexibility and personal commitment to empathy, the actual fieldwork exhibited unprecedented positive impacts. Many field coordinators were being encouraged and capable to negotiate also improvements in local basic infrastructure and effectively increased local bridging social capital. Moreover, with their stories of personal success congruent with local cultural standards and immediate capacities, many field assistants seemed to inspire other community members as particularly realistic and appealing role models.
Participatory data collection methods gather important perspectives that enrich the evaluation of the impact of social policies. Several barriers can be found in the recruitment of vulnerable groups affected by the policy, from time constraints to negativism, mistrust or overburden, but their lived experience is worth the effort. Frontline professionals working with them may be a complementary source of information and can help to reach them.2
Involvement in partnered research of social organisations like Caritas requires a mutual understanding and constant dialogue with academic groups, and a balance between research needs, its priority mission of social care, and avoiding false expectations in participating users. Nevertheless, the voice of these organisations is highly valued by society and can maximise research impact.2 (see box)
In focus. Partnered research on housing and health
Partnership of Caritas Barcelona led to the design of a study of users in vulnerable housing situation. The baseline survey was featured in a Caritas report. Caritas reputation was key to bring the study to the frontpage of most local newspapers (upper photo: press conference). 5
Similarly, the report with results of the online survey of participants in the Mortgage Affected Platform was launched on the eve of the admission to the regional parliament of a citizens‘ petition on housing policies. The day after, the Platform handed the report to all parties in the parliament while collecting their written commitment on the approval calendar (lower photo).
Social media are good channels to increase the reach of politically relevant research
Why is it important? Research is often being performed by institutions and in ways detached from policymakers and the civil society, resulting in low practical value of research results. In relation to research on health equity and social determinants of health, on top of the usual lack of links between executives and academics, additional inter-sector barriers exist. However, the social relevance of this research is also an opportunity and can raise the interest of multiple sectors.
What we did. We engaged in a variety of channels to disseminate the project results besides standard scientific articles and conferences, such as website, social media sites, videos, press release, public seminars and direct stakeholders contact.
What we found. Active dissemination requires time and resources but gives important returns in terms of impact on different professional sectors, the public opinion, and policy. Moving from least to most complex, Slideshare is a very simple platform to make publicly available the work that researchers happen to present in seminars and conferences, while high quality videos can have a very high reach but its preparation can be especially time-consuming. In between lie: an updated and well organised website, an active Twitter account covering not only project achievements and new resources available but also related content, and press releases, policy brief or infographics of selected studies. The use, in addition to English, of local languages for locally relevant content, is also important to expand the reach of research findings. Finally, personal contacts facilitate access to politicians, who nevertheless can get to know policy-relevant findings through traditional mass media or Twitter.
Box 3. In focus. From the video to politics
In May 2014 we launched a video showing the health equity benefits of a urban renewal plan implemented in Catalonia in the past decade.6 This video reached a journalist, who made an article on a major newspaper on the study. Politicians from the former government that launched the plan largely shared the article in social networks, and in subsequent several media appearances used the "health benefits argument" to defend the plan and their government legacy. A reintroduction of the plan is now on the agenda of the newly elected progressive coalition in Barcelona municipality.
Potential Impact:
Policy implications
Economic recessions, fiscal policies and health
• Even though recessions may reduce mortality in the short term, those positive effects may be more than compensated by the mortality increasing effect of austerity policies, at least as far as some causes of mortality are concerned.
• Social protection policies appear to be effective in limiting the sensitivity of mortality to macroeconomic fluctuations.
• Interventions to protect and promote mental health, to prevent suicides and to treat mental disorders become especially relevant in times of economic hardship.
Generous social protection policies reduce poverty and improve health
Health benefits can arise from increasing unemployment insurance generosity, specifically:
• to ensure that the majority of unemployed individuals receive unemployment benefits,
• to ensure flexible eligibility criteria that take into account different types of work and work situations including: seasonal work, reduced hours and self-employment,
• to ensure an adequate income replacement rate that meets the cost of living for a healthy life,
• to ensure short or no waiting periods, between the time of job loss and receipt of unemployment insurance benefits, and,
• to provide unemployment insurance benefits for the whole duration of unemployment.
Policy interventions that maintain employment, and rapidly return the unemployed back into the workforce, can reduce the burden of chronic conditions in European health care systems.
Increased active labour market policies spending can result in improved population health.
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality
• The growth of precarious employment must be halted, and jobs should become more secure and of better quality in order to protect the health and well-being of workers, and reduce health inequalities.
• To measure and monitor precarious and informal employment, as well as worker participation in European countries, standardised definitions and indicators have to be developed as well as improved surveys and information systems.
• Issues concerning decent work, fair employment and precarious employment should be fully considered in both national and European public health policies and political initiatives.
• Employment security and the quality of psychosocial working conditions and work-family balance should be improved, also for self-employment and micro-enterprises.
Urban planning matters for health
The way cities manage density, accessibility, safety and social mix makes a difference in the health of residents, women and elderly being most affected.
The population health in the more deprived areas could benefit from investments in urban regeneration.
Positive outcomes from policies supporting social mix should not be given for granted, as they depend on the scale of the intervention and on the actuation of complementary measures. Similarly, some expected positive impacts from purely physical and infrastructural policies could be hindered when local urban conditions are not favourable.
Policies aiming at "equal" access to recreational facilities, to markets and other core public services may not be enough. Deprived neighbourhoods may need more tailored investments for benefiting from the health promoting role of urban density, access to public spaces and facilities, and a vital mix of functions.
Housing policies can reduce health inequalities
Public policies that tackle housing instability and their consequences are urgently needed in Southern European countries.
Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, targeting the most affected groups and adapted to their needs.
Gender equality policies influence gender inequalities in health
Policies that support women’s participation in the labour force and decrease their burden of care, as for example increasing public services and support for families and entitlement for fathers, are related to lower levels of gender inequalities in health.
Public services and benefits for disabled and dependent people can reduce the burden placed on their family caregivers, improving their health.
The intersectionality perspective should be taken into account as a health equity audit in the design and evaluation of policies and reinforced in research on health inequalities.
Integration policies matter for immigrants’ health
Different integration policy models across Europe appear to make a difference on immigrants’ health.
Adopting restrictive policies in areas related with immigrants’ integration may have health consequences.
Legal barriers in the entitlement to public healthcare systems hinder immigrants’ access to necessary care.
Maximising the social impact of health equity research
Participation of affected populations and frontline professionals adds value to policy evaluations and research.
Face to face contact, respect and gaining the trust are key for the effective involvement of stakeholders in research and in the use of findings.
Researchers should make efforts to actively disseminate through emerging social channels their work and knowledge on social and political determinants of health, and funding agencies and research institutions should back these efforts.
At the end of 2015, we have published 51 articles in peer-reviewed journals, three PhD dissertations, six reports and three report chapters, and presented 63 conference communications, a pre-conference and two plenaries. Our website has been constantly updated and has maintained a monthly average of over 1,000 visits; our Twitter account has shared relevant material daily and has reached 800 followers; we have shared 89 presentations and 9 documents in our Slideshare account, with over 30,000 views; we have produced two videos in three languages on “Urban renewal and health” and "Gender equality and health" that have totalled around 4,000 views each through Youtube and Vimeo, two infographics and six Storify stories; we have issued six press releases and received extensive media coverage of some of our studies; we have shared our results with local and European-level stakeholders and policymakers by inviting them to our final events in Brussels and Barcelona, speaking in policy seminars, holding face-to-face meetings or mailing our conclusions document.
List of Websites:
Project website: www.sophie-project.eu
Please find a web version of our conclusions, including Figures and References, at www.sophie-project.eu/pdf/conclusions.pdf
Social and economic policies can change the extent of social inequalities in health
During these years, SOPHIE has contributed to the accumulation of evidence regarding the influence of social and economic policies on the level of health of the population and on the extent of inequalities in health status on grounds of socioeconomic position, gender or immigrant background. At the same time, SOPHIE has shown, through the analysis of several examples across Europe, how equity-oriented policies can achieve a reduction of these health inequalities. These studies provide a strong case for public health and social justice advocates claiming for fairer social and economic policies, as a way to reach the reduction of health inequalities which most governments are putting among their targets.
What we found and what are the implications for policy
Economic recessions, fiscal policies and health. The health impact of the recent Great Recession in Europe depends on the health indicator, country level of social protection, and individual socioeconomic position and gender. Social protection policies appear to be effective in limiting the sensitivity of mortality to macroeconomic fluctuations. Besides, interventions to protect and promote mental health, to prevent suicides, to treat mental disorders and to prevent harmful drinking become especially relevant in times of economic hardship.
Even though recessions may reduce mortality in the short term, those positive effects may be more than compensated by the mortality increasing effect of austerity policies, at least as far as some causes of mortality are concerned.
Generous social protection policies reduce poverty and improve health. Generous unemployment insurance policies reduce material hardship and psychological distress for the unemployed and the employed. Health benefits can arise from increasing unemployment insurance generosity, specifically to ensure that the majority of unemployed individuals receive unemployment benefits; flexible eligibility criteria that include work situations such as seasonal work, reduced hours and self-employment; an adequate income replacement rate that meets the cost of living for a healthy life; short or no waiting periods between job loss and receipt of benefits and provision of benefits for the whole duration of unemployment.
A large proportion of new onset of chronic illness is attributable to unemployment. Policy interventions that maintain employment, and rapidly return the unemployed back into the workforce, can reduce the burden of chronic conditions in European health care systems.
Generous family support policies are predictive of less child poverty. Increased active labour market policies spending is linked to better population health. Opposition efforts to social protection cuts are successful when the target group is politically powerful.
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality. To measure and monitor precarious and informal employment and their health impact, standardised definitions and indicators have to be developed as well as strongly improved surveys and information systems. Employment conditions and quality of employment and their relation with health inequalities differ between and within EU-countries. The growth of precarious employment must be halted, and jobs should become more secure and of better quality in order to protect the health and well-being of workers, and reduce social inequalities in health.
Employment security and the quality of psychosocial working conditions and work-family balance should be improved, also for self-employment and micro-enterprises. Labour market policies such as employment protection legislation, part-time arrangements or workers' safety representatives impact on workers’ health.
Urban planning matters for health equity. Social and functional mix, density, safety and accessibility all matter for health, therefore the way cities manage urban planning makes a difference in the health of residents, especially women and elderly. Policies aiming at equal access to recreational facilities, markets and other core public services may not be enough: deprived neighbourhoods may need more tailored investments for benefiting from the health promoting role of urban density, access to public spaces and facilities, and a vital mix of functions.
As an example, the population health in the more deprived areas could benefit from investments in urban regeneration. Different urban renewal projects have been shown to have a positive impact on self-reported health and the reduction of socioeconomic health inequalities, or to stimulate healthy behaviours, but not to reduce traffic injuries.
Housing policies can reduce health inequalities. A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. In Europe, housing conditions related to fuel poverty are unevenly distributed and affect health. Housing insulation for fuel-poor households can improve health and reduce cold-related mortality. Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, targeting the most affected groups and adapted to their needs.
Public policies that tackle housing instability and their consequences are urgently needed especially in Southern European countries, where people facing housing exclusion experience dramatic levels of mental distress. Access to secure and adequate housing can improve health of these populations.
Gender policies influence gender inequalities in health. Gender inequalities in health are larger in countries with policies less oriented towards gender equity. Policies that support women’s participation in the labour force and decrease their burden of care, as for example increasing public services and support for families and entitlement for fathers, are related to lower levels of gender inequalities in health. Parental leave reserved for both parents with universal coverage and earning replacement, and working time flexibility to balance family demands seem to contribute to equalising gendered time use. Public services and benefits for disabled and dependent people can reduce the burden placed on their family caregivers, improving their health.
Integration policies make a difference on immigrants’ health. Different integration policy models across Europe appear to make a difference on immigrants’ health. Immigrants in "exclusionist" countries, with severe restrictions in access to citizenship and little policies for integration, suffer poorer health, more depression and higher mortality. Therefore, adopting restrictive policies in areas related with immigrants’ integration may have health consequences. Within the healthcare sector, legal barriers in the entitlement to public systems hinder immigrants’ access to necessary care.
Lessons learned on the research process that can inform future studies
Evaluating structural policies is a new methodological challenge. Mixed methods are essential to such evaluation, and we found that a combination of quantitative and qualitative including realist approaches yielded evidence that was strong, rich and relevant.
Quantitative cross-national comparisons provided novel knowledge on the association of broad policy ‘regimes’ with health inequalities, especially in yet less explored fields. Most comparative studies would not have been possible without the many European-wide surveys initiated in the last 10 to 15 years, and we strongly recommend further development of these surveys.
When available, quasi-experimental data (e.g. time-trend or pre-post intervention-control) could yield stronger evidence, although usually referred to specific interventions with small impact as compared to the current magnitude of health inequalities.
Despite several challenges in their application, realist approaches help to address new and vital questions about how policies achieve impacts and under which conditions. Moreover, as the impacts of changing contexts and policies differ at the intersection of different axes of inequality, the intersectionality perspective should be taken into account in the design and evaluation of policies and reinforced in research on health inequalities.
Community and civil society participation in health equity research is a costly and long-term but worthwhile process. Participation of affected populations and frontline professionals adds validity to policy evaluations and research, and the voice of frontline organisations is highly valued by society and can maximise research impact. Face to face contact, respect and gaining the trust are key for the effective involvement of stakeholders in research and in the use of findings.
Beyond scientific dissemination, social media are good channels to increase the reach of politically relevant research. Researchers should make efforts to actively disseminate through emerging social channels their work and knowledge on social and political determinants of health, and funding agencies and research institutions should back these efforts.
(Please find a web version of our conclusions at www.sophie-project.eu/pdf/conclusions.pdf)
Project Context and Objectives:
Health inequalities are unfair and avoidable differences in health between population groups defined socially, economically, demographically or geographically. They are strongly affected by the circumstances in which people are born, grow, live, work and age, and by the policies influencing these circumstances.
SOPHIE has aimed to generate new evidence on the impact of structural policies on health inequalities, and to develop innovative methodologies for the evaluation of these policies in Europe.
Its specific objectives were:
To generate new evidence on how structural policies - macro-economy, welfare state, employment relations, unemployment, built environment and housing policies - impact the determinants of health inequalities by gender, migration status and socio-economic position.
To generate evidence on how gender-oriented and immigration-related policies impact health inequalities, as well as the determinants of these inequalities.
To develop, refine and apply innovative methods for the identification and evaluation of how structural policies impact health inequalities at the European, national and local levels.
To develop, refine and apply innovative methodologies to increase the involvement of affected stakeholders (civil society, deprived social classes and ethnic minorities, women, immigrants) in the identification, design and evaluation of policies to reduce health inequalities.
To disseminate the findings and recommendations on how structural policies reduce health inequalities by implementing strong knowledge translation approaches to affected communities, stakeholders and responsible policymakers.
Project Results:
Economic recessions, fiscal policies and health
Has the Great Recession been bad for health? It depends.
Why is it important? Recessions – by their very definition – have severe adverse economic effects, in terms of increasing unemployment and poverty rates. What appears less clear is what the health effects of recessions have been, and in particular those of the recent recession (the “Great Recession”) that took off in 2008. Knowing what the likely effects of recessions are can usefully inform policy measures to mitigate or prevent potential adverse health effects.
What we did. We assessed the impact of macroeconomic fluctuations (including recessions and booms) on a battery of overall and cause-specific mortality rates for a sample of European Union countries. We examined in particular the effect of the Great Recession. To this end, we carried out a regression analysis, using country-level, annual data on mortality rates, health behaviour proxies, socioeconomic and demographic indicators for 23 European Countries covering the period from 2000 to 2010, taken from WHO and Eurostat databases.
What we found. Overall, during the recent recession, a 1% increase of the standardised unemployment rate has been associated with a statistically significant decrease in all-cause-mortality, cirrhosis- and chronic liver disease-related mortality, motor vehicle accident-related mortality, parasitic infection-related mortality, but an increase in the suicide rate. In general, the effects were more marked in countries with lower levels of social protection, compared to those with higher levels (Figure 1). 1
In other more methodological work we found results of the effect of recession on mortality does differ in critical ways according to the specific methodology applied.2
Detailed country-specific analysis on Spain provided a more complex picture of the health effects resulting from recessions: while we confirmed the counter-intuitive result that a recession, even one that has been as severe as the recent Spanish one, may have improved overall self-reported health, some dietary behaviour was shown to have deteriorated, as well as mental health in men, and some socioeconomic inequalities in health and health behaviour have widened. 3,4
While recessions may have reduced mortality rates, austerity regimes appear to have increased them.
Why is it important? Some have also argued quite vocally that austerity policies are responsible for some deterioration in health care and health outcome indicators. Yet it is not easy to separate the effects of recession from those of austerity, as both often coincide. Again, knowing the health effects is important, as it can help appreciate the full range of costs (and benefits) of austerity policies.
What we did. We assessed the impact of austerity policies, while controlling for the impact of recession, on a set of overall and cause-specific mortality rates, again for a sample of EU countries. In order to measure austerity, we borrow an indicator that has commonly been used in the macroeconomic literature (‘Blanchard Fiscal Index’), including it in our standard regression model as an additional explanatory variable, using data from 23 European countries covering the period 1991-2011.
What we found. Using - for the first time in this literature - a direct measure of austerity policies, we find that across Europe austerity is associated with an increase in all-cause mortality, injury mortality, cardiovascular disease mortality and suicide mortality (Figure 2). However, where there is a mortality increasing effect of austerity, that effect is partly compensated by a mortality decreasing effect of recessions, with the exception of suicides, that appear to receive a double ‘boost’ from both austerity and recessions.
In focus: Economic crises and alcohol consumption: a realist systematic review 5
Economic crises are complex events that affect behavioural patterns (including alcohol consumption) via opposing mechanisms. With this realist systematic review, we aimed to investigate evidence from studies of previous or ongoing crises on which mechanisms play a role among which individuals, in order to understand and predict the potential impact of economic crises on alcohol consumption. We found 16 studies with evidence on two behavioural mechanisms by which economic crises can influence alcohol consumption and alcohol-related health problems. The first mechanism suggests that psychological distress triggered by unemployment and income reductions can increase drinking problems. The second mechanism suggests that due to tighter budget constraints, less money is spent on alcoholic beverages. Across many countries, the psychological distress mechanism was observed mainly in men. The tighter budget constraints mechanism seems to play a role in all population subgroups across all countries covered in the included studies. For other mechanisms (i.e. deterioration in the social situation, fear of losing one's job, and increased non-working time), empirical evidence was scarce or absent, or had small to moderate coverage. This review suggests that among men (but not among women), the net impact of economic crises will be an increase in harmful drinking. This could potentially contribute to growing gender-related health inequalities during a crisis.
Generous social protection policies reduce poverty and improve health
Generous unemployment insurance policies reduce material hardship for the unemployed and psychological distress also for the employed
Why is it important? There is evidence that supports the link between unemployment, poverty and ill health. Limited work has examined the mediating impacts of unemployment insurance on poverty and health, and whether these associations between countries vary in relation to the different generosity levels of their unemployment insurance systems.
What we did. We undertook a realist review to examine how and why unemployment insurance policies impact poverty and health in different welfare states.1,2
What we found. The generosity of unemployment insurance eligibility, duration and wage replacement levels can reduce poverty, material hardship and psychological distress among the unemployed. It is also related with the psychological distress among the employed population. Generous unemployment insurance policies can moderate harmful consequences of unemployment.3,4
In focus. Generous family support policies are predictive of less child poverty
We performed a realist scoping review of the literature and we found that generous family support policies (FSP) reduce child poverty because they support and increase the freedom of parents to ensure their children are receiving basic opportunities. Family support policies include job-protected leave that enables new parents to remain attached to paid employment after childbirth (i.e parents have the legal right to keep their jobs), public childcare that offers affordable options for parents (i.e. children receive inexpensive or subsidized care during work hours), paid leave that replaces lost incomes (i.e. parents receive a ratio of benefits relative to their gross earning), and cash transfers that offset the material costs of raising children (i.e. parents receive tax-free family payments or allowances). Moreover, when FSP are comprehensive, universal (i.e. available for everyone) and packaged as ‘dual-earner policies’ (i.e. available for both parents), child poverty is the lowest. 5
Health improves as states increase spending on active labour market policies
Why is it important? The primary goal of active labour market policies (ALMPs) is to increase the employment opportunities for job seekers and to improve matching between jobs and workers. In so doing ALMPs can reduce unemployment and benefit dependency, and together with passive labour market policies (mainly unemployment insurance), they act as important forms of social protection for workers. There is little evidence on the impact of ALMPs on health.
What we did. Using a pooled cross-sectional analysis of 20 European nations and 5 welfare regimes, we examined the association between active and passive labour market policy expenditures and self-rated health, adjusting for other individual and macro-level factors.
What we found. Increased spending on ALMPs was associated with better self-rated health (significantly among men).6
In focus. Unemployment, a major cause of chronic illness
Using a multilevel, longitudinal analysis across the EU, we examined the effects of short-term and long-term unemployment, and unemployment insurance generosity, on health. We found that unemployment insurance system generosity was not associated with health in the total sample, although, the longer individuals were unemployed the worse their health. In particular, almost one-fifth of new onset chronic conditions (18%) were attributable to unemployment pattern, more than sex and educational attainment (see Figure 1). 7
Opposition efforts to social protection cuts are successful when the target group is politically powerful
Why is it important? Social protection policies are critical in providing a safety net for citizens. Although during economic crises, many countries apply austerity measures in hope of restoring the economy. This threat of cuts to social protection policies can have a damaging effect on the health and well-being of citizens.
What we did. To understand why and how policies resist austerity, we conducted a set of theory-driven explanatory case studies, interviewing politicians, policymakers and civil society members.
What we found. We found strong evidence that opposition to cuts to fuel poverty programmes and policies, during times of austerity, is successful when the target group is politically powerful (i.e. electoral power). For example, the Winter Fuel Payment (WFP) in England is the only fuel poverty programme or policy that has been maintained during a time of widespread austerity (after 2010) because the elderly (the target recipients) have high voting turnout, and are a core constituency of the incumbent conservative party. Our research shows that even despite the fact that approximately 80% of the elderly who receive the WFP do not actually live in fuel poverty, they all still receive the payment. The conservative party has maintained the WFP to the elderly, whether they are fuel poor or not, “because by and large they vote”. 8
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality
Surveys are useful for monitoring employment conditions and their impact on work-related health (inequalities) but they must be strongly improved.
Why is it important? In contemporary labour markets, where the old standard stable, full time employment is decreasing, the quality of employment involves a serious threat to workers’ health. Low quality employment and resulting situations of employment precariousness, as well as informal employment, are not well conceptualised and measured leading to unsatisfactory estimations of their impact on health. 1
What we did. We defined new multidimensional concepts for measuring employment quality, employment precariousness and informal employment and their health impact in contemporary European labour markets.2 Based on these concepts, a protocol for determining proxy indicators of employment quality3 and precarious employment4,5 was applied to the data from different surveys. We also performed scoping reviews of informal employment to identify the best definition and measure for health inequalities studies. 6,7
What we found. Factors determining the quality of employment in Europe can be summarised in five different types of jobs regarding their employment quality3: SER-like (similar to the ideal standard employment relation), Instrumental (relatively stable but with few benefits), Portfolio (highly skilled but rather flexible), Precarious unsustainable (with adverse employment conditions and relations) and Precarious intensive (with the most adverse scores, especially regarding on work intensity and high flexibility) (Figure 1). Precarious employment is far broader than simple dichotomies between standard and non-standard employment – and constitutes an important social determinant of health in contemporary labour markets.2 Precarious and informal employment definitions differ across countries.3,4,6 Precarious employment should be studied using a common definition with a multidimensional perspective;2 informal employment should be conceptualised and measured with reference to the level of informality6 and social protection7.
In focus. Employment precariousness in Catalonia
To study the prevalence of precarious employment in Catalonia (Spain), measured with a multidimensional scale, and its association with mental and self-rated health, we identified proxy indicators using data from the II Catalan Working Conditions Survey (2010).We found that the prevalence of precarious employment in Catalonia was high (42.6%) and that it was higher in women (51.4%), youth (86.6%), immigrants (67%), and manual (48%) and less educated workers (51.3%). There was a positive gradient (3 times higher) in the association between precarious employment and poor mental (Figure 3) and self-rated health. Our conclusion is that precarious employment is associated with poor health in the working population. Working conditions surveys should include questions on multidimensional precarious employment and health indicators, which would allow monitoring and subsequent analyses of health inequalities.5
Employment conditions and quality of employment and their relation with health inequalities differ between and within EU-countries.
Why is it important? Working and employment conditions under which people work constitute one of the most powerful social determinants of health during adult life. The contemporary world of work entails many old and more recent challenges for health and well-being.
What we did. Using different European surveys (European Social Survey (ESS) and European Working Conditions Survey (EWCS)), we analysed quality of employment and its relation with health. 8,9,10 We also analysed precarious employment and its relation with health using Employment Precariousness Scale (EPRES) for Spain11and informal employment using data available from EWCS12.
What we found. The quality of employment clearly differs between EU-countries, leading to generally high quality employment in the Nordic countries and high rates of precarious employment in Southern-European and Eastern-European countries and it is clearly related to self-perceived job satisfaction, general health (Figure 2) and mental health8. Country differences related to quality of employment are also affecting class and gender-based socio-economic inequalities in (mental) health9,10, making employment quality an important determinant of health inequalities. The prevalence of precarious employment has increased between 2005 and 2010 (48% vs. 51%), being higher among women, manual workers, immigrants and workers with low education attainment and with temporary contracts. Precariousness also impacts mental health5 (Figure 3) even among permanent workers11.
In focus. Self-employed persons in Sweden
Self-employed persons and their enterprises are important to the economy for their contribution to economic development. However, an understanding of the relationship between the psychosocial working conditions, the work-life balance and outcomes, such as health and wellbeing among the self-employed and micro-enterprises, is limited. Data from the European Social Survey show that men and women who are self-employed experience a lower level of work-life balance compared to other groups of employees. Self-employment is positively related to subjective well-being, but differences arise between different groups of the self-employed, with those who are self-employed with employees reporting a higher level of life satisfaction than the self-employed without employees. The analyses also point to different patterns for female and male self-employment without employees and for immigrant groups compared to natives. Data about Swedish self-employed persons also show that all-cause mortality is high in some sectors like Manufacturing and Mining or Trade and Communication in working life and that there are 8-16% higher mortality risks among sole-proprietorship, compared to limited partnership13,14,15.
Labour market policies impact on workers’ health
Why is it important? Labour legislation plays a critically important role in providing a framework for fair and efficient employment relations that eventually deliver fair and decent employment.
What we did. We performed a realist review of how and why employment protection legislation impacts temporary employment16 and a systematic review to summarize the scientific evidence about the relationship between part-time employment (PTE), working and employment conditions and health status and the potential reasons of the heterogeneous results.17 We also undertook case studies to analyze specific employment-policies and interventions in different countries.18-22
What we found. Labour market, social and employment policies have led to the precarization of the European labour market creating worse working and employment conditions. Employment protection legislation was particularly under attack, before the outbreak of the economic and financial crisis increasing inequalities and insecurity of workers and also precarious employment.16 The relationship between PTE, working and employment conditions and health status depends, considerably, on welfare state types, gender, PTE measurement and their voluntary or forced nature.17
In focus. The Belgian Service Voucher System, health and health inequalities.
We have investigated the quality of work in the service voucher system. This study has shown that policy makers have paid substantial attention to the employment conditions (training, working hours, contract duration) in the system, but that debates on the other characteristics of the quality of work are scarce. Several changes have been made to improve the stability of the employment contracts, but some employers apply illegal practices to get around regulation. Given the vulnerability of some service voucher employees, more wage transparency and payments toward social security benefits are needed. This case study has shown that inequalities exist between service voucher employees, related to the Social Paritary committee, between for-profit and not-for-profit organizations, between native workers and immigrant workers.18
In focus. Worker participation in occupational health and preventive action.
Workplace representative participation contributes to the preservation of workers' health. However, some groups of workers may not benefit from their representatives’ action due to their employment conditions. We analysed the impact of labour market precarization on the relationship between workers and their representatives in occupational health,19,20 as well as its consequences on preventive action drawing on data from a Spanish National Working Conditions Survey (2011)21. Workers reporting to have representatives were protected by greater preventive action at their workplaces than workers reporting not to have representatives or unaware of their existence.
Urban planning matters for health
Social and functional mix, density and accessibility matter for mortality and mental health
Why is important. People living in urban setting constitute the larger and increasing proportion of the European population. Urban planning, comprising residential areas, public spaces, services and infrastructures, is acknowledged to be an important policy area for promoting wellbeing inside cities, however its health equity impact is still barely evaluated.
What we did. In few European metropolitan areas we compared with a population cohort approach mortality (Torino, Barcelona, Stockholm, Helsinki)1 and antidepressant drug consumption (Torino)2 of people living in urban areas that were exposed to a different mix of social or physical characteristics as a result of urban structure. We used data from Longitudinal Studies, combined with census data, and only for Torino we collected and mapped data on urban transformation in the last 30 years.
The urban planning choices that stay behind such differences are intended to drive the main aspects of the built and social environment that are potential determinants of health impacts according to several literature reviews. 3,4,5,6 The relative contribution of these determinants of the social and built environment to the trend of inequalities in mortality in an urban setting (Torino) has been estimated compared to the contribution of the individual and social determinants.7,8
What we found. As expected, the individual indicators of social disadvantage show the strongest contribution to inequalities in mortality8 and mental health2, but the deprivation of the neighbourhood where we live also plays a significant and independent role in the risk of premature mortality 8.
Part of this contextual effect may be due to segregation of population of lower socioecononomic position to disadvantaged neighbourhoods, as unintended consequence of urban transformations and interventions. 1
On the other side, the study in Torino 2 suggests that part of this contextual effect may be due to the built environment itself: in fact minor depressive disorders, a health outcome more sensitive to short term impact, seem to benefit from higher urban density and better accessibility by public transport; women and elderly are the most exposed to neighbourhood characteristics, reporting more significant health impacts. However these features of urban structure protecting mental health (accessibility and density) are evenly distributed across social groups in the city and do not contribute to health inequalities, at least in the case of Torino.
We found that only few studies in Europe tried to assess health inequalities linked to built environment, and that results are highly influenced by the local context, making it difficult to generalize conclusions.5 However local studies maintain particularistic importance for informing local decision making with local evidence.
Urban renewal: positive impact on self-reported health, no impact on road safety
Why is important. In the last decades interventions of urban regeneration have been undertaken in most metropolitan areas for improving the built and social environment of the most deprived areas or dismissed industrial areas, and for creating new transport facilities and infrastructures. The impacts on health and equity of such interventions are not given for granted and deserve attention.
What we did. In a first case study the effects of a large scale urban renewal project (Llei de Barris), combining actions on the built and social environment, on self-rated health and health inequalities in Barcelona have been studied through a quasi-experimental study.9 The case study was complemented by collecting residents’ perceptions on changes in their neighbourhoods with Concept Mapping10 and by using a theory-driven realist approach to explore the complex causal pathways between urban renewal and health inequality 11. A second case study addressed the safety impact of an infrastructural intervention: road traffic injuries trend in the catchment area of the third segment of new subway in Torino has been compared before and after the new metro line opening, using a control area in the same city. 12
What we found. In Barcelona, residents perceived the majority of implemented renewal interventions as having positive and important effects on their wellbeing.10 After renewal, self-rated health improved in the intervened neighbourhoods, most notably among manual social class residents, while no changes were seen in the comparison neighbourhoods (Figure 2). 9
Conversely, in Torino, where we measured registered accidents and not a self-reported measure, the new metro line intervention did not reveal significant reduction in the frequency of road injuries in the catchment area. 6
In focus. Effects of a new metro line in Turin
We assessed the impacts of the new metro line in Torino: contrary to expectations based on the literature, we found that no appreciable reduction in road traffic injuries took place; also gentrification effects (increase in real estate values, displacement of disadvantaged residents) were not spread along the whole metro line, but concentrated in few areas. The particular urban structure of the area, where the metro line is running along the railway line, which also constitutes a barrier towards one side of the city, and the distribution of important facilities as interchange parks, university, shopping mall, is able to strongly interact with the envisaged effects of urban interventions.6
This demonstrates that there are more influential elements than an efficient underground public transport able to generate impacts at urban level. The most important finding however is that an intervention can cause different effects according to the local context and characteristics of the area: urban interventions should therefore be accurately studied, and a case-by-case impact assessment should be performed every time.
Urban renewal can stimulate healthy behaviours
Why is important. Healthy behaviours that are usually socially patterned may be influenced by many aspects of the social and built environment. Physical activity in adults is expected to be facilitated by creation and maintenance of safe environments by urban planning. At the same time built environment and neighbourhood quality may play an important role in teenagers behaviours, especially in relation to substance and alcohol abuse.
What we did. A series of studies in the Netherlands were looking at how safe neighbourhoods could promote physical activity in the general adult population: a quasi-experimental evaluation of the Dutch District Approach tried to assess the impact of area-based initiatives on physical activity trends and safety indicators in deprived areas,13-17 and a companion realist review uncovered how area-based initiatives may stimulate leisure-time walking among adults in deprived areas.18 Another study focused on health behaviours of Prague teenagers, that are at the top of health risk behaviour around Europe, collecting data on characteristics of home and school built environment, neighbourhood quality, and on the prevalence of health risk behaviours by means of a survey.19
What we found. In the Dutch quasi-experiment, safe neighbourhoods promote walking in the general adult population, especially among those living in deprived areas, primarily by stimulating them to walk in leisure time; realist review explained that urban renewal stimulates residents to walk by providing safer, more relaxing, and more convenient environments to walk through. In the Czech cross-sectional study adolescents health risk behaviours seem not to be related to home neighbourhood environment, but rather to the school environment, especially in its outdoor features.
Housing policies can reduce health inequalities
In Europe, housing conditions related to fuel poverty are unevenly distributed and affect health
Why is it important? A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. Access to adequate housing conditions is determined by the interaction between the housing system and the welfare state. A country’s housing system is in turn the result of the interaction between the housing market and housing policies developed over time (Figure 1).1
Figure 1. Conceptual framework on housing systems, housing conditions and health equity.
One of the important aspects of housing related to health, mainly during the economic recession, is the presence and increase of fuel poverty,defined as the difficulty of keeping a house at a comfortable temperature and to meet its energy needs at an affordable cost. Major revisions have compiled abundant evidence on the association between fuel poverty, and its derived thermal discomfort and humidity, and cardiovascular and respiratory diseases, depression, and anxiety. Moreover, a significant percentage of excess winter mortality may be related to fuel poverty.2
What we did.Using the 2012 European Union Statistics on income and living conditions (EU-SILC), we obtained for 29 European countries and for the 5 welfare state regimes in which they are classified (social democratic, corporatist, liberal, southern and transition) the prevalence of poor housing conditions related with fuel poverty (dampness, house not adequately warm, arrears on utility bills) and their association with self-rated health, among population aged 16 or over in the two lower equalised income quintiles. For the same countries, we computed the Excess Winter Deaths Index (EWDI) for 2011-12.3
What we found. In all countries, poor housing conditions related with fuel poverty are associated with poor health, even adjusting for material deprivation. These conditions are poorer and EWDI higher in transition countries and in southern European countries mainly due to the poor quality of the housing stock, rises in fuel prices,and low expenditure on housing policy, particularly in instruments such as housing benefits or fuel benefits.3 This situation has worsened in the countries most affected by the global financial crisis such as Greece or Spain.
Housing insulation for fuel-poor households can improve health
Why is it important? Energy efficiency interventions, such as façade retrofitting, can address fuel poverty from a structural and long-term perspective. Despite evidence of the health benefits of insulation, little is known about the political and social contexts contributing to social inequalities in receiving and benefitting from it.2
What we did.We used a realist review methodology to better understand the mechanisms that explain how and why variations in receiving façade retrofitting interventions and in their impact on health determinants occur across different social groups. We reviewed 124 articles considering four stages of implementation: public policy approach; policy; intervention; impact on health determinants.2
What we found. Social groups suffering most from fuel poverty such as low-income, renters or elderly people, experience more barriers for undertaking a building retrofitting. This is due to mechanisms such as the inability to afford initial costs, landlords' lack of incentive to improve energy efficiency, or even in case of public intervention, insufficient attention to residents' needs or preferences. Energy efficiency policies that do not tackle these factors may exacerbate these inequalities.2
In focus. Façade insulation in social housing and cold related mortality in Barcelona
The objective of this study was to evaluate the impact on the association between cold outdoor temperatures and mortality of energy efficiency façade retrofitting of 310 poorly insulated social housing blocks in the city of Barcelona, occurred between 1986 and 2012. The design of the study was a time stratified case cross-over analysis. The impacts of the interventions were different between men and women. Women living in a non-insulated block had a higher risk of death when exposed to extremely cold temperatures on the same day of death and the day before; but these associations were lost for women living in an insulated block (Figure 2). Associations were stronger in women aged 70-79 and with no education. In men, insulation increased the risks of death 14-16 days after an extremely cold temperature day. While façade retrofitting has significantly reduced the risk of cold-related mortality in women, possible negative impacts in men should be studied. 4
Access to secure and adequate housing can improve health
Why is it important? A common feature of housing systems in Europe is the increase in homeownership in most countries, with rising levels of mortgage debt levels. With the onset of the financial and economic crisis, in countries like Spain with little social housing, arrears, evictions and substandard housing arrangements have appeared as a major problem. This may have had an effect on people’s health. Policies to provide affordable housing can improve socioeconomic conditions and in turn health.
What we did. In Spain, Caritas is one of the institutions focused on helping people with housing problems. We aimed to evaluate, with a longitudinal study, the effect of relocation to a new house through social programs of Caritas on health determinants and health outcomes in the Barcelona area. The sample consisted of adults from families in substandard housing in need of housing relocation, or unable to afford their mortgage or rent. They answered a questionnaire interview in 2012 and again one year later.5,6
What we found. The baseline physical and mental health status of Caritas users with housing problems was much worse than that of the general population.5 Relocated people experienced substantial improvements in housing habitability and affordability. They also improved in various health indicators, although they did it in the same way as people not relocated, some of whom also had improved their housing and socioeconomic conditions. Mental health improved more in those who experienced relief in their precarious socioeconomic situation and improvements in housing conditions (Figure 3).6
In focus. Evictions and health: people affected by mortgage in Catalonia
Since the starting of the economic recession, Spain presents very high rates of foreclosures and evictions. In this situation, civil society has self-organized, being the Affected by Mortgage Platform (PAH in Spanish) one of the most important related movements. A self-administered online questionnaire was completed by 905 adults belonging to the PAH and living in Catalonia. We found an extremelyhigh prevalence of poor mental health among PAH participants (87%), much higher than the general population of Catalonia (13% in the last health survey). Poor mental health was significantly higher already in the period of non-payment compared with those who were up-to-date with the payment while self-rated health status was poorer in later steps of the process, such as post-eviction.7
Gender equality policies influence gender inequalities in health
Why is it important? In most high-income countries women have poorer health than men even if they live longer. Policies that promote equality between men and women can partly bridge the gap among genders.
What we did. We performed a systematic review showing initial evidence that policies that promote gender equity reduce gender inequalities and improve women’s health.1 Thereafter, we classified European countries according to their family policy model (Figure 1) and carried out 3 studies that compared men and women’s self-perceived health2, wage-earner men and women’s mental health3 and the relationship between employment and family burden and self-rated and mental health4 in the different family policy models.
Figure 1. Gender inequalities in self-rated health according to family policy model 1
What we found. In traditional (Southern and Central) and contradictory countries women are more likely to report poorer health than men. This is particularly the case for Southern countries (Figure 1).2 Among wage earners, and across different social classes, gender inequalities in mental health are more widespread and pronounced in market-oriented countries than in other typologies.3 The burden of combining employment and family demands seems especially harmful for the self-rated and mental health of women in traditional countries and men in market oriented countries.4
In focus. Parental leave and gendered time use in Sweden and Spain. Time allocation is a highly gendered process and division of work is an important factor in gender equality. Studies have found that an unequal division of work is related to low well-being especially among women. By using Multinational Time Use Study data from Sweden and Spain in 1990, 2000 and 2010, we observed that changes in leave policies introducing or increasing exclusive paternal leave were followed by reductions in inequality in time use between mothers and fathers. Our conclusion is that family policies that support gender equality through earning replacement, parental leave reserved for both parents with universal coverage, and working time flexibility to balance family demands contribute to equalising gendered time use. 5
In focus. Lone mothers’ health in Spain. Lone mothers are a vulnerable group at greater risk of poverty and unemployment even in rich countries. We analysed two Spanish National Health Surveys, 2003 and 2011, and found that lone mothers presented poorer self-rated health, mental health and health-related behaviours than couple mothers. Manual class lone mothers were particularly disadvantaged. Inequalities between lone and couple mothers did not change along the period. In a traditional family model like Spain, with insufficient family support policies for mothers, socio-economic assets are key to determine access to resources producing health inequalities. This could particularly affect Spanish lone mothers.6
Public services for disabled people can improve the health of family caregivers
Why is it important? The adverse effects of family caregiving on physical and mental health are well documented. In Spain, this burden is concentrated among women, mostly of low socio-economic position. The Dependence Act, passed in 2006, represented an advance in social rights by declaring the universal nature of social services and recognising the subjective right of dependent persons to receive an economic contribution to family caregivers and a set of services at home or in care centres. Although its budget implementation has been limited, especially after austerity cuts in 2012.
What we did. Using data from the Spanish National Health Survey 2006 and 2012, we compared the mental health and self-rated general health of cohabitants of a disabled person who were responsible of their care, and non-caregivers.7 We used Concept Mapping to gather views of informal caregivers and primary healthcare professionals on how the Act had influenced the caregivers' quality of life.8
What we found. Between 2006 and 2012, in both sexes the health of family caregivers has improved more than that of non-caregivers (Figure 2).7 Concept mapping showed that the Act brought for caregivers the possibility of sharing the burden of care, reducing its physical, mental and social consequences, while at the same time being able to maintain responsibility on the dependent person. Nonetheless, implementation problems, delays, insufficient budget and austerity cuts in services and benefits were also affecting caregivers negatively. 8
In focus. How to resist austerity: the case of the Gender Budgeting strategy in Andalusia. As a political response to the current economic crisis, important budget cuts in public policies have been implemented as well as the downgrading of gender equality policies. An example of policy that has resisted austerity is the gender budgeting strategy in Andalusia. To understand why and how, we conducted a theory-driven explanatory case study. We interviewed politicians, policymakers and civil society members. The main reasons for the resilience of the strategy include a strong political commitment with a solid female leadership supported by a strong left-wing government, as well as several mechanisms triggered by the previous context of institutionalization of the strategy and the facility provided by its low maintenance cost.9
The intersectionality perspective is important in health equity research and policy evaluation
Why is it important? Socio-economic position, gender, ethnicity or immigrant background are axes of social inequality that interact among each other in creating health inequalities. Thus the design of policies to tackle health inequalities and their evaluation need to take into account all these dimensions, as well as their intersections.
What we did. We have developed a quick guide for incorporating intersectionality in evaluation of policy impacts on health equity, including practical examples based on the experience in the project.10 Whenever possible, we have stratified our analyses by sex, socio-economic position, immigrant background and/or age.
What we found. The impacts of changing contexts and policies differ at the intersection of different axes of inequality. For example, through the economic crisis in Spain, poor mental health increased in middle-aged and manual social class men, but not in other groups,10 and in immigrant more than native men.11 Immigrant background and gender intersect and reinforce one another to produce inequalities in the labour market in Europe, such as in the quality of work, health and safety risk or workplace discrimination.12,13 A qualitative study among domestics working in the service voucher system in Belgium revealed that immigrant women are particularly vulnerable for a poor work quality and work-related health and safety risks. Their negotiation power with clients is hampered by their limited labour market opportunities or problems related to their residence permit.14
Integration policies matter for immigrants’ health
Immigrants in “exclusionist” countries suffer poorer health
Why is it important? Immigrants constitute an increasing proportion of the European population. The debate on policies to control and integrate immigration has been high on the agenda for many years, but very little is known on their health impacts.
What we did. We compared health inequalities between natives and immigrants across European countries that apply different integration policy models (Figure 1):
• The “inclusive” model, characterised by easy acquisition of citizenship and tolerance of cultural differences;
• The “assimilation” model, relatively open on nationality, but restrictive on residence, access to labour market and cultural manifestations in public;
• The “differential exclusionist” or “guest worker” model, basing citizenship on ancestry, characterised by low social and political tolerance and little active integration policies.1
We studied self-rated health using survey data from the 2011 European Union Statistics on Income and Living Conditions, comparing individuals born in the same country of residence or outside the EU and having resided 10 years or more in the country.2 We analysed mortality data of the Netherlands (inclusive), France (assimilationist) and Denmark (exclusionist), comparing people born in Turkey or in Morocco (origins well represented in the three countries) with people born in the same country of residence.3 Using the European Social Survey 2012, we compared depressive symptoms in individuals born in the same country of residence or in less economically developed countries.4
What we found. Inequalities in living conditions and self-rated health between immigrants and natives were highest in exclusionist countries (Figure 2).2 Immigrants also had the highest mortality in Denmark compared to their compatriots in the Netherlands and France (Figure 3).3 Inequalities in depressive symptoms were also largest in exclusionist countries followed by assimilationist countries, and particularly in countries poorly ranked in integration policy comparisons such as Switzerland and Denmark.4
In focus: Discrimination and health among persons with immigrant background in Europe
We used the European Social Survey of 2012 to study the association of perceived membership to a discriminated group and three health indicators among people born abroad or with both parents born abroad (excluding IMF advanced countries), taking into account gender, generation and country integration policy. Perceived membership to a discriminated group was associated with poorer health outcomes, mainly depression, only for first-generation immigrants, and among those, especially in assimilationist countries.5
In focus. Healthcare exclusion in Czechia
In Czechia, regular immigrants without permanent residence are not entitled to public health insurance and should purchase a commercial insurance. With this system, we found that the real access to health services of these immigrants is much lower than that of Czechs and permanent residents;6 and even among these permanent immigrants, many lack knowledge of their rights and remain out of the public system.7
The assessment of health equity impact of structural policies: evaluation of research methods
Evaluating structural policies is a new methodological challenge
The “inverse evidence law” states that the more a policy could impact on population health, the harder it is to convincingly demonstrate this impact. In public health, there is considerable evidence about the health impact of interventions aimed at modifying behavioural factors such as smoking and drinking. Much less is known about policies addressing the wider economic, social and physical environments in which people live (called here ‘structural policies’), despite the intuition of a much larger impact. The challenge of SOPHIE has been to advance in the generation of such evidence.
Approaches aligned with the principles of evidence-based medicine, including before-and-after measurements and control groups, are sometimes applicable in practice to structural policies, even though the researcher does not hold control over the policy execution. In this, we should recognise that most structural policies are inherently complex. Their population health impact may strongly depend on the ways in which they are implemented, the populations that they target, and the wider context. Then, it is problematic to just summarise the evaluation in terms of a simple ‘yes/no effect’. Alternative designs are needed that are able to generate more nuanced insights, and to draw careful lessons that may be transferable to other populations.
Mixed methods are essential to the evaluation of structural policies
In the SOPHIE project, various approaches were used to assess and to understand the impact of structural policies on population health and on health inequalities. It was found that a combination of quantitative and qualitative or realist approaches was essential to fully assess the impact of structural policies. Mixed methods yielded evidence that was strong, rich and relevant.
Quantitative approaches were applied mostly with the aim to assess whether a structural policy has had a demonstrable impact on health-related outcomes, how large this effect appeared to be, and whether this impact differed according to socioeconomic position. Some studies made comparisons between places, such as countries, regions, or small districts, relating variations in structural policies to variation in health outcomes. Other studies made comparisons over time, such as comparisons before/after the introduction of a new policy measure. In time series analyses, more detailed data of trends over time were used to assess whether the introduction of a policy was followed – immediately or gradually – by a change in health outcomes. Finally, some studies applied ‘quasi-experimental’ approaches that combined the geographic and time dimensions, for example, by applying the before-after design to both the population exposed to the intervention and to a control population (e.g. those living in another neighbourhood).
In addition to these quantitative approaches, the SOPHIE project applied in-depth analyses that included qualitative research methods, to identify the mechanisms through which a structural policy could influence population health. Several methods have been used, such as concept mapping and multiple case studies. In particular, we explored the feasibility and informative value of ‘realist’ approaches, including realist reviews and realist evaluations, especially aimed to test expectations regarding how a structural policy could affect population health, and under which condition, i.e. when/where, the same policy would set in motion specific mechanisms.
Quantitative comparative approaches yielded novel knowledge
Most studies performing quantitative comparisons over time and/or place yielded novel evidence on the impact of structural policies on the health of disadvantaged groups such as manual workers, women or ethnic minorities. Some common challenges had to be addressed. In the SOPHIE project, much experience was gained from cross-national comparisons. It was found that the strength of evidence depended on various conditions.
1. The study had to be able to control for confounding by national factors, such as measures of national income. A particular challenge may be to control for other policies that were developed in parallel with the structural policies of interest.
2. The study had to maximise the number of countries studied, which, for Europe, is limited to less than about 30. In particular, the study had to find ways to apply statistical control for several confounders even with such a limited number of countries was limited (e.g. multi-level analysis with control for individual-level confounders).
3. Problems in the comparability of the information on the structural policies of interest may induce systematic or random measurement bias, and affect study outcomes. Using comparable though simplistic indicators may be a solution, but may at the same time cause problems of measurement validity.
Many SOPHIE studies found ways to address these challenges in their particular case, depending on the topic of interest and the data that were available.
The application of time trend analysis, rather than cross-sectional comparisons, yielded stronger evidence on the impact of structural policies. The experience of SOPHIE studies is that stronger evidence could be obtained if:
1. The structural policies of interest rapidly changed over time. Sudden policy changes generate ‘natural policy experiments’ that can be assessed in a quasi-experimental design. In contrast, policy changes that are gradually implemented over a period (say 5 to 10 years) are generally harder to evaluate for their population health impact.
2. The available data sources are continuous (say, monthly, yearly or two-yearly) instead of covering only a few points in time. Continuous time series increase the possibility to accurately follow trends in health-related outcomes after a policy change, and thus to assess lagged dose-response relationships.
3. No major developments occur in other fields. Confounding may occur by concurring changes in other policy areas. Such problems can be solved with multi-country studies that compare ‘experiment’ to ‘control’ countries which differ especially with regards to the policy of interest.
Realist approaches help to address new and vital questions
When applied in isolation, the quantitative approaches may results in simple ‘yes/no’ verdicts regarding the impact of structural policies on health inequalities. ‘Realist’ approaches have been used in the project to address how questions, allowing SOPHIE researchers to disentangle the mechanisms through which structural policies could affect the health of people. By doing this, we were able to formulate policy conclusions that were more nuanced and aligned with the reality of people’s lives. Such detailed knowledge could also help us to formulate lessons that take into account the context, i.e. under which conditions a structural policy would have the promised impact.
The experience of SOPHIE researchers is that, to fully seize the potential of realist approaches, several challenges have to be faced:
1. The strength of the evidence strongly depends on the quality and richness of the information that could be obtained from primary sources or published studies. For example, in a field dominated by quantitative studies, there may be little qualitative information on the mechanisms of interest, and a ‘realist’ synthesis may not have sufficient material to test and refine initial expectations.
2. A clear and efficient working protocol must be developed. Published studies using ‘realist’ approaches greatly varied in the ways in which the studies are executed and results are presented. Further standardisation (see e.g. www.ramesesproject.org) is expected to increase the efficiency, quality and transparency of each individual study.
3. On another level, scientists using ‘realist’ approaches should find ways to deal with the current publication pressure, as these methods can be more time-consuming than quantitative studies and harder to get into most high-impact scientific journals. In similar ways, because of the lack of simple answers, it may be more difficult to disseminate the results to policy-makers or professionals, especially those trained only in positivist, quantitative science.
Yet, ‘realist’ approaches are an indispensible complement to ‘black box’ studies that only aim to demonstrate and quantify the impact of a structural policy. These approaches need to be further developed, applied and promoted in public health.
Implications for policy-oriented research
In future work, stronger evidence on the health equity impact of structural policies could be obtained by further application of the quasi-experimental design, i.e. a pre-post, intervention-control design. As a general rule, the strength of evidence increases with (1) a larger number of control and interventions areas, (2) a more detailed measurement of intervention exposure and of confounders, and (3) the inclusion of more subsequent years of observation.
Qualitative or ‘realist’ approaches are indispensible to understand and predict the impact of structural policies. They can best applied together with a primary, prospective collection of data, such that expectations regarding “mechanisms of change” can be assessed with rigour and detail. Moreover, in the ideal case, these approached are complemented with quantitative comparative approaches that aim to test and quantify the expected health impacts, to simultaneously assess “whether, how much” and “how, when” a structural policy would reduce inequalities in health.
Broad structural policies and ‘regimes’ may be most relevant for the reduction of health inequalities. However, they may be hard to assess for their precise impact, while the variety of mechanisms and context-dependencies may be overwhelming. On the other side, specific structural policies of interest may be assessed with greater detail and rigour, but the demonstrated impact may turn out to be deceptively small as compared to the current magnitude of health inequalities. Further research shall have to find a balance each time between the brush and the tweezers.
In the SOPHIE project, we learned that the key challenge is to get stronger evidence impact of such policies on people’s health. If such an impact could be assessed for a population at large, it is possible in principle to also assess this impact for subpopulations stratified according to socioeconomic position or other axes of inequality, given a sufficient statistical power in the available data.
Novel statistical approaches such as Propensity Score Matching and Difference-in-Difference methods did not appear to offer a satisfactory solution to the key challenges. Often, the key issue was about observation and measurement. In SOPHIE, most comparative studies would not have been possible without the many European-wide surveys that were initiated in the last 10 to 15 years. We strongly recommend further development of these international surveys in the next decade.
Maximising the social impact of health equity research
Community and civil society participation, a costly but worthwhile process
Why is it important? Stakeholders’ involvement in research projects plays a key role in ensuring exploitation of the project results with the aim to tackle health inequalities. It may contribute to the creation of a bridge between stakeholders’ needs and research outputs, hopefully leading to more socially relevant research. However, only few projects and studies make efforts to engage with non-academic stakeholders. Socially disadvantaged groups may be especially hard-to-reach when traditional research methods are used, resulting in under-researched topics and/or data and conclusions of questionable validity.
What we did. Focusing on community-based participatory research (CBPR), one of the most promoted approaches to involve affected communities at all stages of research, we performed a scoping review of 38 full-text articles on CBPR studies addressing in particular ethnic minorities and migrants, aiming to systematize current operationalization of the CBPR concept by researchers, especially of its expected causal roles.1
As regards knowledge transfer, we also conducted an applied ethnography (detailed case study) within the largest state-backed health equity project of its kind focused on segregated Roma communities called Healthy Communities.2
To move from theory to practice, we also drew lessons from different degrees of community partnership experimented in the project, such as Caritas Barcelona participation in the SOPHIE consortium and in housing research. We elaborated a report related to experiences on involvement of different stakeholders into the research process.3
What we found. In the scoping review, we found that CBPR is practically not being used by researchers explicitly as such for research on migrants and ethnic minorities in Europe. Even beyond Europe, that its expected causal roles are being operationalized by the researchers in a rather unsystematic manner. Based on overlaps in the researchers’ impressions, however, several causal mechanisms can be postulated through which particular CBPR features, e.g. sensitive pre-assessment of cultural and social norms, seem to facilitate communities' involvement in research in the area of migrant and ethnic minority health.1
Results of case study of Healthy Communities showed that the community participation concept was not translated into the organizational level as intended within the expert discourses. Despite this conceptual weakness, project appeared successful in fostering intended changes in the target population’s health-related circumstances exactly thanks to its participative features (see box).
Box 1. Mediating health for segregated Roma in Slovakia: An ethnographic case study
Health-mediation programs represent pivotal state-backed health-equity policies addressing segregated Roma communities in Central and Eastern Europe. The Slovak Healthy Communities (HC) program, running for over 10 years, predominantly employing segregated Roma, and now serving nationally in nearly 200 communities under direct supervision of Ministry of Health, counts among the most advanced of these initiatives.
In our applied ethnographic study of the HC program we relied on analyses of documentation, long-term participant observations, and semi-structured interviewing across all organizational levels of the program. We found the program to be rather out-dated and flat on paper conceptually: it set out to emphasize but the targeted population’s health-related behaviour and responsibility and to intervene but through edification and temporary assistance with healthcare access. Nevertheless, thanks to an implicit standard of pragmatic flexibility and personal commitment to empathy, the actual fieldwork exhibited unprecedented positive impacts. Many field coordinators were being encouraged and capable to negotiate also improvements in local basic infrastructure and effectively increased local bridging social capital. Moreover, with their stories of personal success congruent with local cultural standards and immediate capacities, many field assistants seemed to inspire other community members as particularly realistic and appealing role models.
Participatory data collection methods gather important perspectives that enrich the evaluation of the impact of social policies. Several barriers can be found in the recruitment of vulnerable groups affected by the policy, from time constraints to negativism, mistrust or overburden, but their lived experience is worth the effort. Frontline professionals working with them may be a complementary source of information and can help to reach them.2
Involvement in partnered research of social organisations like Caritas requires a mutual understanding and constant dialogue with academic groups, and a balance between research needs, its priority mission of social care, and avoiding false expectations in participating users. Nevertheless, the voice of these organisations is highly valued by society and can maximise research impact.2 (see box)
In focus. Partnered research on housing and health
Partnership of Caritas Barcelona led to the design of a study of users in vulnerable housing situation. The baseline survey was featured in a Caritas report. Caritas reputation was key to bring the study to the frontpage of most local newspapers (upper photo: press conference). 5
Similarly, the report with results of the online survey of participants in the Mortgage Affected Platform was launched on the eve of the admission to the regional parliament of a citizens‘ petition on housing policies. The day after, the Platform handed the report to all parties in the parliament while collecting their written commitment on the approval calendar (lower photo).
Social media are good channels to increase the reach of politically relevant research
Why is it important? Research is often being performed by institutions and in ways detached from policymakers and the civil society, resulting in low practical value of research results. In relation to research on health equity and social determinants of health, on top of the usual lack of links between executives and academics, additional inter-sector barriers exist. However, the social relevance of this research is also an opportunity and can raise the interest of multiple sectors.
What we did. We engaged in a variety of channels to disseminate the project results besides standard scientific articles and conferences, such as website, social media sites, videos, press release, public seminars and direct stakeholders contact.
What we found. Active dissemination requires time and resources but gives important returns in terms of impact on different professional sectors, the public opinion, and policy. Moving from least to most complex, Slideshare is a very simple platform to make publicly available the work that researchers happen to present in seminars and conferences, while high quality videos can have a very high reach but its preparation can be especially time-consuming. In between lie: an updated and well organised website, an active Twitter account covering not only project achievements and new resources available but also related content, and press releases, policy brief or infographics of selected studies. The use, in addition to English, of local languages for locally relevant content, is also important to expand the reach of research findings. Finally, personal contacts facilitate access to politicians, who nevertheless can get to know policy-relevant findings through traditional mass media or Twitter.
Box 3. In focus. From the video to politics
In May 2014 we launched a video showing the health equity benefits of a urban renewal plan implemented in Catalonia in the past decade.6 This video reached a journalist, who made an article on a major newspaper on the study. Politicians from the former government that launched the plan largely shared the article in social networks, and in subsequent several media appearances used the "health benefits argument" to defend the plan and their government legacy. A reintroduction of the plan is now on the agenda of the newly elected progressive coalition in Barcelona municipality.
Potential Impact:
Policy implications
Economic recessions, fiscal policies and health
• Even though recessions may reduce mortality in the short term, those positive effects may be more than compensated by the mortality increasing effect of austerity policies, at least as far as some causes of mortality are concerned.
• Social protection policies appear to be effective in limiting the sensitivity of mortality to macroeconomic fluctuations.
• Interventions to protect and promote mental health, to prevent suicides and to treat mental disorders become especially relevant in times of economic hardship.
Generous social protection policies reduce poverty and improve health
Health benefits can arise from increasing unemployment insurance generosity, specifically:
• to ensure that the majority of unemployed individuals receive unemployment benefits,
• to ensure flexible eligibility criteria that take into account different types of work and work situations including: seasonal work, reduced hours and self-employment,
• to ensure an adequate income replacement rate that meets the cost of living for a healthy life,
• to ensure short or no waiting periods, between the time of job loss and receipt of unemployment insurance benefits, and,
• to provide unemployment insurance benefits for the whole duration of unemployment.
Policy interventions that maintain employment, and rapidly return the unemployed back into the workforce, can reduce the burden of chronic conditions in European health care systems.
Increased active labour market policies spending can result in improved population health.
High quality employment in a regulated labour market is beneficial for workers’ health and reduces inequality
• The growth of precarious employment must be halted, and jobs should become more secure and of better quality in order to protect the health and well-being of workers, and reduce health inequalities.
• To measure and monitor precarious and informal employment, as well as worker participation in European countries, standardised definitions and indicators have to be developed as well as improved surveys and information systems.
• Issues concerning decent work, fair employment and precarious employment should be fully considered in both national and European public health policies and political initiatives.
• Employment security and the quality of psychosocial working conditions and work-family balance should be improved, also for self-employment and micro-enterprises.
Urban planning matters for health
The way cities manage density, accessibility, safety and social mix makes a difference in the health of residents, women and elderly being most affected.
The population health in the more deprived areas could benefit from investments in urban regeneration.
Positive outcomes from policies supporting social mix should not be given for granted, as they depend on the scale of the intervention and on the actuation of complementary measures. Similarly, some expected positive impacts from purely physical and infrastructural policies could be hindered when local urban conditions are not favourable.
Policies aiming at "equal" access to recreational facilities, to markets and other core public services may not be enough. Deprived neighbourhoods may need more tailored investments for benefiting from the health promoting role of urban density, access to public spaces and facilities, and a vital mix of functions.
Housing policies can reduce health inequalities
Public policies that tackle housing instability and their consequences are urgently needed in Southern European countries.
Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, targeting the most affected groups and adapted to their needs.
Gender equality policies influence gender inequalities in health
Policies that support women’s participation in the labour force and decrease their burden of care, as for example increasing public services and support for families and entitlement for fathers, are related to lower levels of gender inequalities in health.
Public services and benefits for disabled and dependent people can reduce the burden placed on their family caregivers, improving their health.
The intersectionality perspective should be taken into account as a health equity audit in the design and evaluation of policies and reinforced in research on health inequalities.
Integration policies matter for immigrants’ health
Different integration policy models across Europe appear to make a difference on immigrants’ health.
Adopting restrictive policies in areas related with immigrants’ integration may have health consequences.
Legal barriers in the entitlement to public healthcare systems hinder immigrants’ access to necessary care.
Maximising the social impact of health equity research
Participation of affected populations and frontline professionals adds value to policy evaluations and research.
Face to face contact, respect and gaining the trust are key for the effective involvement of stakeholders in research and in the use of findings.
Researchers should make efforts to actively disseminate through emerging social channels their work and knowledge on social and political determinants of health, and funding agencies and research institutions should back these efforts.
At the end of 2015, we have published 51 articles in peer-reviewed journals, three PhD dissertations, six reports and three report chapters, and presented 63 conference communications, a pre-conference and two plenaries. Our website has been constantly updated and has maintained a monthly average of over 1,000 visits; our Twitter account has shared relevant material daily and has reached 800 followers; we have shared 89 presentations and 9 documents in our Slideshare account, with over 30,000 views; we have produced two videos in three languages on “Urban renewal and health” and "Gender equality and health" that have totalled around 4,000 views each through Youtube and Vimeo, two infographics and six Storify stories; we have issued six press releases and received extensive media coverage of some of our studies; we have shared our results with local and European-level stakeholders and policymakers by inviting them to our final events in Brussels and Barcelona, speaking in policy seminars, holding face-to-face meetings or mailing our conclusions document.
List of Websites:
Project website: www.sophie-project.eu
Please find a web version of our conclusions, including Figures and References, at www.sophie-project.eu/pdf/conclusions.pdf
