Marcia Gibson

Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews

Background There is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. However, turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development. Methods Systematic review methodology was used to identify systematic reviews (from 2000 to 2007, developed countries only) that described the health effects of any intervention based on the wider social determinants of health: water and sanitation, agriculture and food, access to health and social care services, unemployment and welfare, working conditions, housing and living environment, education, and transport. Results Thirty systematic reviews were identified. Generally, the effects of interventions on health inequalities were unclear. However, there is suggestive systematic review evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment. Conclusion Intervention studies that address inequalities in health are a priority area for future public health research.

Housing and health inequalities: a synthesis of systematic reviews of interventions aimed at different pathways linking housing and health.

Housing and neighbourhood conditions are widely acknowledged to be important social determinants of health, through three main pathways: (1) internal housing conditions, (2) area characteristics and (3) housing tenure. We conducted a systematic overview of systematic reviews of intervention studies to provide an overview of the evidence on the impact of housing and neighbourhood interventions on health and health inequalities. There is relatively strong evidence for interventions aimed at improving area characteristics and compelling evidence for warmth and energy efficiency interventions targeted at vulnerable individuals. However, the health impacts of area-level internal housing improvement interventions are as yet unclear. We found no reviews of interventions aimed at altering housing tenure. This remains an important area for further research and potentially new evidence syntheses.

Working for health? Evidence from systematic reviews on the effects on health and health inequalities of organisational changes to the psychosocial work environment.

OBJECTIVE To map the health effects of interventions which aim to alter the psychosocial work environment, with a particular focus on differential impacts by socio-economic status, gender, ethnicity, or age. METHODS A systematic approach was used to identify, appraise and summarise existing systematic reviews (umbrella review) that examined the health effects of changes to the psychosocial work environment. Electronic databases, websites, and bibliographies, were searched from 2000-2007. Experts were also contacted. Identified reviews were critically appraised and the results summarised taking into account methodological quality. The review was conducted in the UK between October 2006 and December 2007. RESULTS Seven systematic reviews were identified. Changes to the psychosocial work environment were found to have important and generally beneficial effects on health. Importantly, five reviews suggested that organisational level psychosocial workplace interventions may have the potential to reduce health inequalities amongst employees. CONCLUSION Policy makers should consider organisational level changes to the psychosocial work environment when seeking to improve the health of the working age population.

Understanding the Psychosocial Impacts of Housing Type: Qualitative Evidence from a Housing and Regeneration Intervention

The association between poor housing and poor health is widely accepted, but there is a lack of evidence on the health impact of housing interventions. In particular, evidence on mechanisms linking housing interventions to health is lacking. Scotlands Housing and Regeneration Project (SHARP) evaluated the health impacts of new-build social housing using a quasi-experimental survey design. Qualitative interviews were also conducted with a sub-sample of survey respondents. The qualitative data indicated that changes in dwelling type influenced key psychosocial processes such as control, with consequent impacts on well-being. This study provided insights into the psychosocial impacts of housing design, whilst also demonstrating the utility of qualitative methods for enhancing understanding of the mechanisms linking housing change with improved well-being.

Lone parents, health, wellbeing and welfare to work: a systematic review of qualitative studies

BackgroundLone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.MethodsWe conducted a systematic review of qualitative studies reporting lone parents’ accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.ResultsScreening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.ConclusionWtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW.

Case Study of Public Health

Umbrella reviews are an established method of locating, appraising, and synthesising systematic review-level evidence. Umbrella review methodology is though only just beginning to emerge as a well-used technique in public health research. This chapter therefore summarises some of the first umbrella reviews conducted in the field of public health with a thematic focus on the social determinants of health and how interventions might affect health inequalities. The chapter discusses some of the cross-cutting methodological and thematic lessons learned from this body of work and concludes by suggesting new directions for umbrella reviews within the field.

Effects of restrictions to Income Support on health of lone mothers in the UK: a natural experiment study

Summary Background In the UK, lone parents must seek work as a condition of receiving welfare benefits once their youngest child reaches a certain age. Since 2008, the lower age limit at which these Lone Parent Obligations (LPO) apply has been reduced in steps. We used data from a nationally representative, longitudinal, household panel study to analyse the health effects of increased welfare conditionality under LPO. Methods From the Understanding Society survey, we used data for lone mothers who were newly exposed to LPO when the age cutoff was reduced from 7 to 5 years in 2012 (intervention group 1) and from 10 to 7 years in 2010 (intervention group 2), as well as lone mothers who remained unexposed (control group 1) or continuously exposed (control group 2) at those times. We did difference-in-difference analyses that controlled for differences in the fixed characteristics of participants in the intervention and control groups to estimate the effect of exposure to conditionality on the health of lone mothers. Our primary outcome was the difference in change over time between the intervention and control groups in scores on the Mental Component Summary (MCS) of the 12-item Short-Form Health Survey (SF-12). Findings The mental health of lone mothers declined in the intervention groups compared with the control groups. For intervention group 1, scores on the MCS decreased by 1·39 (95% CI −1·29 to 4·08) compared with control group 1 and by 2·29 (0·00 to 4·57) compared with control group 2. For intervention group 2, MCS scores decreased by 2·45 (−0·57 to 5·48) compared with control group 1 and by 1·28 (−1·45 to 4·00) compared with control group 2. When pooling the two intervention groups, scores on the MCS decreased by 2·13 (0·10 to 4·17) compared with control group 1 and 2·21 (0·30 to 4·13) compared with control group 2. Interpretation Stringent conditions for receiving welfare benefits are increasingly common in high-income countries. Our results suggest that requiring lone parents with school-age children toseek work as a condition of receiving welfare benefits adversely affects their mental health. Funding UK Medical Research Council, Scottish Government Chief Scientist Office, and National Health Service Research Scotland.

Making the most of natural experiments: What can studies of the withdrawal of public health interventions offer?

Many interventions that may have large impacts on health and health inequalities, such as social and public health policies and health system reforms, are not amenable to evaluation using randomised controlled trials. The United Kingdom Medical Research Councils guidance on the evaluation of natural experiments draws attention to the need for ingenuity to identify interventions which can be robustly studied as they occur, and without experimental manipulation. Studies of intervention withdrawal may usefully widen the range of interventions that can be evaluated, allowing some interventions and policies, such as those that have developed piecemeal over a long period, to be evaluated for the first time. In particular, sudden removal may allow a more robust assessment of an interventions long-term impact by minimising ‘learning effects’. Interpreting changes that follow withdrawal as evidence of the impact of an intervention assumes that the effect is reversible and this assumption must be carefully justified. Otherwise, withdrawal-based studies suffer similar threats to validity as intervention studies. These threats should be addressed using recognised approaches, including appropriate choice of comparators, detailed understanding of the change processes at work, careful specification of research questions, and the use of falsification tests and other methods for strengthening causal attribution. Evaluating intervention withdrawal provides opportunities to answer important questions about effectiveness of population health interventions, and to study the social determinants of health. Researchers, policymakers and practitioners should be alert to the opportunities provided by the withdrawal of interventions, but also aware of the pitfalls.

Health impacts of UK Lone Parent Obligations: a natural experiment study using data from the UK household panel survey, Understanding Society

Abstract Background In the UK, lone mothers receiving income support are required to seek work as a condition of receiving that support once their youngest child reaches a specified age. Since 2008, the lower age limit at which these so-called Lone Parent Obligations (LPO) apply has been reduced in steps. We aimed to assess the health impact of exposing increasing numbers of lone parents to welfare conditionality. Methods We carried out a natural experimental study in the UK using data from Understanding Society, a UK household longitudinal panel study (2009–13). The primary outcome was the mental health component of SF-12. The physical health component of SF-12 and self-rated health were secondary outcomes. Lone mothers newly exposed to LPO when the age limit was reduced to 7 years old and then to 5 (two intervention groups) were compared with lone mothers who remained unexposed (control 1) or who were exposed before the change (control 2). A difference-in-difference linear regression analysis was conducted on an intention-to-treat basis, adjusting for maternal age, education, and number of children. Findings The total sample size was 2359, 291 in the intervention groups (146 age 7 years, 145 age 5 years) and 1966 in the control groups (711 control 1, 1357 control 2). Mental health of lone mothers declined in intervention groups compared with control groups. The mental health component score for lone mothers newly exposed to LPO with children aged 4–6 years changed by −1·39 (95% CI −4·08 to 1·29) compared with unexposed lone mothers and by −2·29 (−4·57 to 0·00) compared with previously exposed lone mothers. Data for the two intervention groups combined were, respectively, −2·13 (−4·17 to −0·10) and −2·21 (−4·13 to −0·30). No impact on SF-12 physical health component scores or on self-rated health was found. Interpretation In the UK, welfare conditionality appears to have adversely impacted mental health of lone mothers. The study only investigated short-term effects, but the pattern of findings was consistent over the two age comparison groups. Welfare conditionality is increasingly common in high-income countries; possible adverse impacts should be considered rather than assuming that all impacts will be positive. Further research should ascertain longer-term effects of exposure to LPO and the effects of the further reduction in the age threshold from 5 to 3 years in 2017. Funding NHS Research Scotland senior clinical fellowship (SCAF/15/02), Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15), Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15).

OP76 Evaluating the health impacts of restrictions to income support for lone parents: a natural experiment study using understanding society

Background Lone parents experience poorer health and socioeconomic disadvantage compared to coupled parents. The UK Government has restricted access to Income Support, the primary income replacement benefit for lone parents. Under Lone Parent Obligations (LPO), lone parents are transferred from Income Support to Jobseeker’s Allowance once their youngest child reaches an age threshold (which has been reduced incrementally), and they must prove they are actively seeking work or face sanctions. We investigated the effects of introducing LPO on the health of lone mothers in the UK. Methods We analysed 2009–2013 data from Understanding Society, a panel study representative of the UK general population. Our primary outcome was the mental health component of SF-12, with the physical health component and self-rated health assessed as secondary outcomes. We identified two intervention groups: lone parents newly exposed following the cut-off change from seven to five years and from ten to seven years. Each of these intervention groups were compared to two control groups: remaining unexposed (since the youngest child was below the age cut-off), and already exposed (since the youngest child was older than the existing age cut-off). We estimated a pooled LPO effect to increase precision. We conducted a difference-in-difference analysis using linear regression to estimate the ‘intention to treat’ causal effect, adjusting for maternal age, number of children and maternal education. Multiple imputation was used to address item missingness. Results Our primary analysis included a total of 2257 participants. Mental health of lone parents consistently declined in intervention groups compared to control groups, whereas physical health and self-rated health showed little change. For lone parents with children aged 5–7 years who were newly exposed, the mental health score of SF-12 changed by −1.39 (95%CI −4.08,1.29) compared to those unexposed and −2.29 (95%CI −4.57,0.00) compared to those remaining exposed. Equivalent figures for the cut-off change from 10–7 years were −2.45 (95%CI −5.48,0.57) and −1.28 (95%CI −4.00,1.45), while for the pooled effect were −2.13 (95%CI −4.17,−0.10) and −2.21 (95%CI −4.13,−0.30). A complete case analysis and inclusion of males within the analytical sample led to similar results. Discussion Increasing conditionality attached to the receipt of welfare benefits adversely impacted mental health of lone mothers but had no short-term impacts on physical health. Our study had limited statistical power and was only able to investigate short-term effects, but the pattern of findings was consistent across comparison groups. Planned extensions to LPO should be reconsidered.