Over the past 40 years, many health-care systems that were once publicly owned or financed have moved towards privatising their services, primarily through outsourcing to the private sector. But what has the impact been of privatisation on the quality of care? A key aim of this transition is to improve quality of care through increased market competition along with the benefits of a more flexible and patient-centred private sector. However, concerns have been raised that these reforms could result in worse care, in part because it is easier to reduce costs than increase quality of health care. Many of these reforms took place decades ago and there have been numerous studies that have examined their effects on the quality of care received by patients. We reviewed this literature, focusing on the effects of outsourcing health-care services in high-income countries. We found that hospitals converting from public to private ownership status tended to make higher profits than public hospitals that do not convert, primarily through the selective intake of patients and reductions to staff numbers. We also found that aggregate increases in privatisation frequently corresponded with worse health outcomes for patients. Very few studies evaluated this important reform and there are many gaps in the literature. However, based on the evidence available, our Review provides evidence that challenges the justifications for health-care privatisation and concludes that the scientific support for further privatisation of health-care services is weak.

In this paper, we examine the labour market effects of lowering the UK's benefit cap in 2016. This policy limits the total amount a working-age non-disabled household with no-one in employment can receive in social security. We treat the sharp reduction in this benefit cap as a natural experiment, comparing those at risk of being capped and those who were not before and after the cap was lowered. Drawing on data from ~500,000 individuals, we find that this reform reduced unemployment compared to those not at risk of being capped. The reform also increased economic inactivity, partly because the cap harmed mental health but also because those at risk of being capped were eligible to claim disability-related welfare payments that made them exempt. Limiting total monthly welfare payments of low-income families may increase employment for some but it can also push others out of the labour market altogether.

Agnogenic practices—designed to create ignorance or doubt—are well-established strategies employed by health-harming industries (HHI). However, little is known about their use by industry-funded organizations delivering youth education programmes. We applied a previously published framework of corporate agnogenic practices to analyse how these organizations used them in three UK gambling industry-funded youth education programmes. Evidential strategies adopted previously by other HHI are prominent in the programmes’ practitioner-facing materials, evaluation design and reporting and in public statements about the programmes. We show how agnogenic practices are employed to portray these youth education programmes as ‘evidence-based’ and ‘evaluation-led’. These practices distort the already limited evidence on these educational initiatives while legitimizing industry-favourable policies, which prioritize commercial interests over public health. Given the similarities in political strategies adopted by different industries, these findings are relevant to research and policy on other HHI.

Socio-economic inequalities in mental health problems are found in measures covering prevalence, treatment utilisation, and treatment helpfulness. However, whether these inequalities exist globally and what factors explain between-country variation is unclear. We use a nationally representative individual-level survey dataset (Wellcome Global Monitor, 2020) in 111 countries (N = 117,088) to test if socio-economic factors (household income, education), psycho-social factors (stigma perception, trust in health professionals) and country-level factors (GDP, Gini, health expenditure) predict (1) self-reported lifetime prevalence of anxiety and depression symptomology, (2) treatment utilisation and (3) perceived treatment helpfulness talking to a mental health professional and taking prescribed medication. Multi-level logistic regression models were used. Across both HICs and LMICs, being in the richest income quintile within each country is associated with a lower probability of experiencing symptoms of anxiety and depression compared to the poorest quintile (OR = 0.67 CI[0.64–0.70]), as well as a higher probability of talking to a mental health professional (OR = 1.25[1.14–1.36]), and of perceiving this treatment as very helpful (OR = 1.23[1.07–1.40]). However, being among the richest income quintile is not associated with taking prescribed medication (OR = 0.97[0.89–1.06]) and its perceived helpfulness (OR = 1.06[0.94–1.21]) across all countries. Trust in health practitioners is associated with higher mental health professional utilisation (OR = 1.10[1.06–1.14]) and helpfulness (OR = 1.32[1.25–1.40]). This analysis reveals a global ‘triple inequality in mental health’, whereby disadvantages of lower SES individuals persist in three outcomes (lifetime prevalence, treatment utilisation and helpfulness). Treatment utilisation and helpfulness also vary by trust in healthcare professionals and treatment type. Policymakers must address all three inequalities and their fundamental causes.

This paper makes a major intervention in the historiography of elites through analysis of the experience of women occupational elites born in post-war Britain. The paper draws on a new set of oral history interviews recently conducted with women born in the post-war decades with an entry in Who’s Who which is the leading biographical dictionary of ‘noteworthy and influential’ people in the UK. The women we interviewed were all highly occupationally successful and those analysed here also attended one of twelve elite girls’ schools. This article argues that our interviewees can be separated into two distinct post-war cohorts: one born between early 1940s and mid-1950s and the other born late 1950s to late 1960s. The shape and structure of the cohort’s trajectories were different, their relationship to their careers were different, and, even though both groups faced sexual discrimination and unequal divisions of labour, the nature of these gendered inequalities changed too. By foregrounding elite women within this shifting historical context, this article illuminates broader trends in both classed and gendered experience and how this related to the changing nature of the economy in recent history.

Elites often use merit to explain, justify, and make sense of their advantaged positions. But what exactly do they mean by this? In this paper, we draw on 71 interviews with elites in Denmark and the UK to compare self-justifications of meritocratic legitimacy. Our results indicate that while elites in both countries are united by a common concern to frame their merits as spontaneously recognized by others (rather than strategically promoted by themselves), the package of attributes they foreground vary significantly. In the UK, elites tend to be “talent meritocrats” who foreground their unique capacity for ideational creativity or risk taking, innately good judgment, and “natural” aptitude, intelligence, or academic ability. In contrast, in Denmark, elites are more likely to be “hard work meritocrats” who emphasize their unusual work ethic, extensive experience (as a signal of accumulated hard work), and contributions outside of work, particularly in civil society. We tentatively argue that one explanation for this cross-national variation is the role that different channels of elite recruitment play in amplifying legitimate notions of merit. In the UK, for example, elite private schools act to nurture ideas of exceptionalism and natural talent, whereas in Denmark elite employers socialize the connection between hard work and success. These findings suggest that nationally specific understandings of merit can have quite different implications for the legitimation of inequality.

The growing body of scholarship on the commercial determinants of health has, so far, mostly employed qualitative methods but this is now being complemented by a small, yet growing, corpus of quantitative studies. We illustrate the use of one such method, quantitative text analysis (QTA), in a case study of submissions to a public consultation on a draft scientific opinion by the European Food Safety Authority on the chemical acrylamide, demonstrating how this method can be used and insights that might be drawn from it. We use Wordscores as one example of QTA to illuminate the diverse positions taken by actors submitting comments and then assess whether the final policy documents moved towards or away from the positions taken by different stakeholders. We find a broadly uniform position among the public health community, opposed to acrylamide, contrasting with industry positions that were not monolithic. Some firms recommended major amendments to the guidance, largely reflecting the impact on their practices, while policy innovators seeking ways to reduce acrylamide in foods aligned with the public health community. We also find no clear movement in the policy guidance, likely because most submissions supported the draft document. Many governments are required to conduct public consultations, some attracting enormous numbers of responses, with little guidance on how best to synthesise the responses so the default position is often a count of those for and against. We argue that QTA, primarily a research tool, might usefully be applied in analysing public consultation responses to understand better the positions taken by different actors.

Processes of public engagement in decision-making and research are increasingly discussed as ways of addressing democratic deficits in high-income countries. In this paper, we explore why these processes of engagement and involvement in the UK have been less successfully incorporated into social security policymaking aimed at the out-of-work by drawing a comparison with health policy, a sphere in which these processes have now become orthodox (albeit imperfect). There is, for example, no formal or institutionalised imperative to involve people with lived experience of out-of-work social security benefits in processes of policy development. Government departments might focus group new policies with members of the public or hold periodic discussions with beneficiaries but in recent years there have been a number of major reforms to out-of-work social security which have been developed almost entirely without involving those affected. This would have been unacceptable in the health policy arena. We argue that this difference is rooted in structural differences in how the field of power for this form of social policy is organised, in the different social imaginaries which construct patients and out-of-work beneficiaries, and in the limited scope for solidarity and collective action around resisting the stigmatisation of out-of-work beneficiaries.

A large literature has demonstrated the link between poverty and mental ill-health. Yet, the potential causal effects of poverty alleviation measures on mental disorders are not well-understood. In this systematic review, we summarize the evidence of the effects of a particular kind of poverty alleviation mechanism on mental health: the provision of cash transfers in low- and middle-income countries. We searched eleven databases and websites and assessed over 4,000 studies for eligibility. Randomized controlled trials evaluating the effects of cash transfers on depression, anxiety, and stress were included. All programs targeted adults or adolescents living in poverty. Overall, 17 studies, comprising 26,794 participants in Sub-Saharan Africa, Latin America, and South Asia, met the inclusion criteria of this review. Studies were critically appraised using Cochrane’s Risk of Bias tool and publication bias was tested using funnel plots, egger’s regression, and sensitivity analyses. The review was registered in PROSPERO (CRD42020186955). Meta-analysis showed that cash transfers significantly reduced depression and anxiety of recipients (dpooled = -0.10; 95%-CI: -0.15, -0.05; p < 0.01). However, improvements may not be sustained 2–9 years after program cessation (dpooled = -0.05; 95%-CI: -0.14, 0.04; ns). Meta-regression indicates that impacts were larger for unconditional transfers (dpooled = -0.14; 95%-CI: -0.17, -0.10; p < 0.01) than for conditional programs (dpooled = 0.10; 95%-CI: 0.07, 0.13; p < 0.01). Effects on stress were insignificant and confidence intervals include both the possibility of meaningful reductions and small increases in stress (dpooled = -0.10; 95%-CI: -0.32, 0.12; ns). Overall, our findings suggest that cash transfers can play a role in alleviating depression and anxiety disorders. Yet, continued financial support may be necessary to enable longer-term improvements. Impacts are comparable in size to the effects of cash transfers on, e.g., children’s test scores and child labor. Our findings further raise caution about potential adverse effects of conditionality on mental health, although more evidence is needed to draw robust conclusions.

Despite its significance in determining poverty risk, family size has received little focus in recent social policy analysis. This paper provides a correction, focusing squarely on the changing poverty risk of larger families (those with three or more dependent children) in the UK over recent years. It argues that we need to pay much closer attention to how and why poverty risk differs according to family size. Our analysis of Family Resource Survey data reveals how far changes in child poverty rates since 1997 – both falling poverty risk to 2012/13 and increases since then – have been concentrated in larger families. Social security changes are identified as central: these have affected larger families most as they have greater need for support, due to both lower work intensity and higher household needs. By interrogating the way policy change has affected families of different sizes the paper seeks to increase understanding of the effects of different poverty reduction strategies, with implications for policy debates in the UK and beyond. In providing evidence about the socio-demographics of larger families and their changing poverty risk it also aims to inform contested debates about the state’s role in providing financial support for children.

In this article we investigate whether quantifying school performance can have the unintended consequence of increasing the spatial concentration of advantage. Combining research on residential segregation with the sociology of quantification, we argue that ranking school performance may induce affluent parents to sort into areas with higher-ranked schools. We explore this hypothesis by analyzing linked decennial census data from 1981 to 2011 to examine whether the introduction of league tables measuring school performance in the early 1990s in England affected the spatial concentration of advantage. We find that the introduction of league tables was associated with an increase in the geographical concentration of occupational class. Advantaged households containing children became more likely to move to areas with better-performing schools after the introduction of league tables compared to less advantaged households. Quantifying school quality has the unintended consequence of increasing the geographical concentration of advantage, potentially entrenching inequalities.

Private schools have long played a crucial role in male elite formation but their importance to women’s trajectories is less clear. In this paper, we explore the relationship between girls’ private schools and elite recruitment in Britain over the past 120 years – drawing on the historical database of Who’s Who, a unique catalogue of the elite. We find that alumni of elite girls schools have been around 20 times more likely than other women to reach elite positions. They are also more likely to follow particular channels of elite recruitment, via the universities of Oxford and Cambridge, private members clubs and elite spouses. Yet such schools have also consistently been less propulsive than their male-only counterparts. We argue this is rooted in the ambivalent aims of girls elite education, where there has been a longstanding tension between promoting academic achievement and upholding traditional processes of gendered social reproduction.

What explains variation across countries in the effect of democratization on child mortality rates? Democratic transitions, on average, improve health outcomes but there is substantial variation across countries in whether democratization leads to lower-than-expected child mortality post-transition. As yet, there is no convincing quantitative explanation for this variation. In this paper, we argue that whether you have a protest-led or violence-led democratic transition alters the trajectory of child mortality post-transition. Our paper makes two contributions. First, we offer a more detailed account of how the type of resistance movement promoting regime change affects health post-transition. We also draw on novel data to categorise the movements producing democratic transitions as violent or peaceful, moving beyond earlier work which operationalised peaceful democratizations in terms of battle-related deaths. Second, we extend earlier research by examining whether the nature of the democratization movement constitutes a necessary cause of higher or lower-than-expected child mortality following democratization. Across 51 transitions, countries that have a protest-led transition have lower-than-expected child mortality rates after the transition to democracy than countries with other kinds of movements (β = −0.17, p = 0.003). Countries with violence-led transitions, meanwhile, have, on average, higher-than-expected child mortality rates after their transition (β = 0.20, p = 0.001). These associations hold when we adjust for covariates (including all possible combinations of various confounding variables). We also find evidence that protest-led transitions may be a necessary condition for avoiding increased child mortality post-transition. Finally, we conduct a deviant case analysis of transitions that appear to be contrary to our theory, finding that these cases are likely instances of measurement error. Democratization may not always improve health, but such health improvements are more likely when regime change is protest-led. This is because such movements are more likely to build broad coalitions committed to consensual politics post-transition, a critical feature of successful democracies.

Background: Does increased female participation in the social and political life of a country improve health? Social participation may improve health because it ensures that the concerns of all people are heard by key decision-makers. More specifically, when women’s social participation increases this may lead to health gains because women are more likely to vote for leaders and lobby for policies that will enhance the health of everyone. This article tries to examine whether female participation is correlated with measures of health inequality.

Methods: We draw on data from the World Health Organization Health Equity Status Report initiative and the Varieties of Democracy project to assess whether health is better and health inequalities are smaller in countries where female political representation is greater.

Results: We find consistent evidence that greater female political representation is associated with lower geographical inequalities in infant mortality, smaller inequalities in self-reported health (for both women and men) and fewer disability-adjusted life-years lost for women and men. Finally, we find that greater female political representation is not only correlated with better health for men and women but is also correlated with a smaller gap between men and women because men seem to experience better health in such contexts.

Conclusions: Greater female political representation is associated with better health for everyone and smaller inequalities.

Collective bargaining institutions are correlated with better population health. However, there are still major gaps in our understanding regarding the impact of collective bargaining on health inequalities, particularly between labour market ‘insiders’ and ‘outsiders’. In this study, we investigate the effect of collective bargaining coverage on individuals’ self-rated health, and whether the impact varies according to labour market status. We use four waves of the European Values Survey (1981–2018) and three-level nested random intercept models across 33 OECD and European countries (N=66,301). We find that stronger and more inclusive collective bargaining institutions reduce health inequalities between the unemployed and the employed by disproportionately improving the health of the unemployed. This study implies that targeting the political institutions that shape the distribution of power and resources is important for reducing health inequalities.

Unaffordable housing has many dimensions, not least its far-reaching implications for mental health. Although the psycho-social effects of housing affordability stress are well documented there is a lack of research on their variation within or between cohorts who have shared experiences of housing (social generations). This article fills that gap by following 14,000 Australians in the national Household, Income and Labour Dynamics survey for 16-years as they enter and exit unaffordable housing. We model when cohorts seem most vulnerable to mental health effects of unaffordable housing. We find contemporaneously that while people born in the 1980s have a high likelihood of falling below the affordability threshold, older people have a lower likelihood of recovering. These trends create a ‘pinch point’ for this older generation with negative mental health consequences. We position housing affordability stress as an indicator of precarity whose mental health effects may vary both within cohorts and between generations as a product of their shared experiences of housing.

Background: The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England.

Methods: For this observational study, we used a novel database composed of parsable procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645,674, value >£25,000, total value £204·1 billion), across 173 clinical commissioning groups (CCGs; regional health boards) in England. Data were compiled from 12,709 heterogenous expenditure files primarily scraped from commissioner websites with supplier names matched to registers identifying them as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. We used multivariate longitudinal regression models with fixed effects at the CCG level to analyse the association of for-profit outsourcing on treatable mortality rates in the following year. We used the average marginal effects to estimate total additional deaths attributable to changes in for-profit outsourcing. We provided alternative model specifications to test the robustness of our findings, match on background characteristics, examine the potential impact of measurement error, and adjust for possible confounding factors such as population demographics, total CCG expenditure, and local authority expenditure.

Findings: We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable mortality of 0·38% (95% CI 0·22–0·55; p=0·0016) or 0·29 (95% CI 0·09–0·49; p=0·0041) deaths per 100,000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153–961) treatable deaths across the 173 CCGs.

Interpretation: The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013–20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.

In this study, we examine whether welfare deservingness judgements in the United Kingdom are affected by a bias against claimants from stigmatised social class backgrounds. In the United Kingdom, as in other countries, stereotypes of a perceived social ‘underclass’ are widespread. Political and media discourse frequently portrays members of this ‘underclass’ as lazy, feckless and not genuinely in need of support. Yet despite strong academic interest in perceived welfare deservingness, existing research has largely neglected the role of social class bias in deservingness judgements. To address this gap, we use a novel vignette experiment administered to a representative sample of British respondents to provide the first direct evidence of discrimination against welfare claimants with ‘underclass’ signifiers. We find that the British public are more likely to endorse a sanction against a claimant from an ‘underclass’ background than against an otherwise identical claimant from a less stigmatised class background. We also asked respondents to justify their decisions and, applying computational methods to analyse these free-text responses, we find that ‘underclass’ claimants are more likely to be blamed for violating the conditions of their benefit, while claimants from other class backgrounds are more often given the ‘benefit of the doubt.’ Our findings have important implications for our understanding of the relationship between social class background and public deservingness perceptions, and potentially for the differential treatment of claimants by the benefits system.

Background: Lower incomes are associated with poorer mental health and wellbeing, but the extent to which income has a causal effect is debated. We aimed to synthesise evidence from studies measuring the impact of changes in individual and household income on mental health and wellbeing outcomes in working-age adults (aged 16–64 years).

Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, PsycINFO, ASSIA, EconLit, and RePEc on Feb 5, 2020, for randomised controlled trials (RCTs) and quantitative non-randomised studies. We had no date limits for our search. We included English-language studies measuring effects of individual or household income change on any mental health or wellbeing outcome. We used Cochrane risk of bias (RoB) tools. We conducted three-level random-effects meta-analyses, and explored heterogeneity using meta-regression and stratified analyses. Synthesis without meta-analysis was based on effect direction. Critical RoB studies were excluded from primary analyses. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This study is registered with PROSPERO, CRD42020168379.

Findings: Of 16,521 citations screened, 136 were narratively synthesised (12·5% RCTs) and 86 meta-analysed. RoB was high: 30·1% were rated critical and 47·1% serious or high. A binary income increase lifting individuals out of poverty was associated with 0·13 SD improvement in mental health measures (95% CI 0·07 to 0·20; n=42,128; 18 studies), considerably larger than other income increases (0·01 SD improvement, 0·002 to 0·019; n=216,509, 14 studies). For wellbeing, increases out of poverty were associated with 0·38 SD improvement (0·09 to 0·66; n=101,350, 8 studies) versus 0·16 for other income increases (0·07 to 0·25; n=62,619, 11 studies). Income decreases from any source were associated with 0·21 SD worsening of mental health measures (–0·30 to –0·13; n=227,804, 11 studies). Effect sizes were larger in low-income and middle-income settings and in higher RoB studies. Heterogeneity was high (I2=79–87%). GRADE certainty was low or very low.

Interpretation: Income changes probably impact mental health, particularly where they move individuals out of poverty, although effect sizes are modest and certainty low. Effects are larger for wellbeing outcomes, and potentially for income losses. To best support population mental health, welfare policies need to reach the most socioeconomically disadvantaged.

Homeless individuals are more likely than others to experience a traumatic brain injury (TBI), but it is uncertain if such individuals are more likely to experience neuropsychiatric illnesses. Methods. A systematic review was performed with searches in Medline, Embase, and PsychINFO for studies reporting on homeless persons with TBI and neuropsychiatric illnesses. A random-effects model was used to calculate odds ratios for having any neuropsychiatric diagnosis. Results. Of 420 articles indexed, 19 were included for systematic review and 17 for meta-analysis reporting on 11,474 and 8,757 individuals, respectively. The pooled odds of a homeless individual with a TBI having any neurologic illness were 2.57 (95% CI [1.97, 3.44]; I2 = 68.0%) and 2.01 (95% CI [1.81, 2.25]; I2 = 79.2%) for any psychiatric illness. Conclusions. The odds of having a neuropsychiatric illness among homeless individuals with TBI are substantially higher than in the domiciled population with TBI.

Poverty alleviation programs, such as cash transfers and monetary grants, may not only lift people out of poverty but, some argue, may improve mental health as well. However, to date, the impact of such programs on children and adolescents’ mental health is unclear. We carried out a systematic review and meta-analysis of poverty alleviation interventions providing monetary support and reporting mental health outcomes in 0–19 year olds in low-, middle-, and high-income countries. We searched 11 databases for research published between January 1, 1990 and June 1, 2020 and included interventions offering unconditional and/or conditional monetary support and reporting mental health outcomes. After screening 7,733 unique articles, we included 14 papers (16,750 children and adolescents at follow-up) in our narrative summary. We meta-analyzed data on internalizing symptoms from 8 papers (13,538 children and adolescents analyzed). This indicated a small but significant reduction in adolescents’ internalizing problems postintervention compared to control (odds ratio 0.72, 95% confidence interval 0.59–0.88, p < .01; I2 = 67%, τ2 = 0.05, p < .01). Our narrative synthesis provides further support for the overall effectiveness of cash programs but also notes that monetary support alone may not be sufficient in extreme risk settings and that imposing conditions may be actively harmful for the mental health of adolescent girls. We provide causal evidence that monetary interventions reduce internalizing symptoms of adolescents experiencing poverty. We recommend that future programming thoughtfully considers whether to apply conditions as part of their interventions and highlight the importance of providing additional comprehensive support for children and adolescents living in extreme risk settings.

Purpose: It is unclear how hospitals are responding to the mental health needs of the population in England, against a backdrop of diminishing resources. We aimed to document patterns in hospital activity by psychiatric disorder and how these have changed over the last 22 years.

Methods: In this observational time series analysis, we used routinely collected data on all NHS hospitals in England from 1998/99 to 2019/20. Trends in hospital admissions and bed days for psychiatric disorders were smoothed using negative binomial regression models with year as the exposure and rates (per 1000 person-years) as the outcome. When linear trends were not appropriate, we fitted segmented negative binomial regression models with one change-point. We stratified by gender and age group [children (0–14 years); adults (15 years+)].

Findings: Hospital admission rates and bed days for all psychiatric disorders decreased by 28.4 and 38.3%, respectively. Trends were not uniform across psychiatric disorders or age groups. Admission rates mainly decreased over time, except for anxiety and eating disorders which doubled over the 22-year period, significantly increasing by 2.9% (AAPC=2.88; 95% CI: 2.61–3.16; p<0.001) and 3.4% (AAPC=3.44; 95% CI: 3.04–3.85; p<0.001) each year. Inpatient hospital activity among children showed more increasing and pronounced trends than adults, including an increase of 212.9% for depression, despite a 63.8% reduction for adults with depression during the same period.

Conclusion: In the last 22 years, there have been overall reductions in hospital activity for psychiatric disorders. However, some disorders showed pronounced increases, pointing to areas of growing need for inpatient psychiatric care, especially among children.

Background: Adverse childhood experiences (ACEs) are strong risk factors for homelessness and poor health and functioning. We aimed to evaluate the lifetime prevalence of ACEs and their associations with health-related and functioning-related outcomes among homeless adults.

Methods: In this systematic review and meta-analysis, we searched from database inception to Nov 11, 2020, for original and peer-reviewed studies in English that documented lifetime prevalence of ACEs or associations between ACEs and health-related or functioning-related outcomes. We selected studies if they included a definable group of homeless adults and measured at least four ACE categories. We calculated pooled estimates of lifetime prevalence of one or more ACEs and four or more ACEs with random-effects models. We used the leave-one-out method in sensitivity analyses and studied meta-regressions to explore potential moderators of ACE prevalence. We also did a narrative summary of associations between ACEs and health-related and functioning-related outcomes, as there were too few studies on each outcome for quantitative meta-analysis. This study is registered with PROSPERO, CRD42020218741.

Findings: We identified 2129 studies through systematic search, of which 29 studies (16,942 individuals) were included in the systematic review, 20 studies (10,034 individuals) were included in the meta-analysis for one or more ACEs, and 15 studies (5693 individuals) were included in the meta-analysis for four or more ACEs. Studies included samples of adults experiencing homelessness in the USA, Canada, and the UK; participants in the included studies were predominantly male (65·2%) and mean ages ranged between 18·3 and 58·1 years, but many studies did not report race, ethnicity, and sexual and gender minority data. Lifetime prevalence of one or more ACEs among homeless adults was 89·8% (95% CI 83·7–93·7) and the lifetime prevalence of four or more ACEs was 53·9% (45·9–61·7). Considerable heterogeneity was identified in both meta-analyses (I2>95%). Of the potential moderators analysed, the ACE measurement tool significantly moderated the estimated lifetime prevalence of one or more ACEs and four or more ACEs, and age also significantly moderated the estimated lifetime prevalence of four or more ACEs. In the narrative synthesis, ACEs were consistently positively associated with high suicidality (two studies), suicide attempt (three studies), major depressive disorder (two studies), substance misuse (two studies), and adult victimisation (two studies).

Interpretation: The lifetime prevalence of ACEs is substantially higher among homeless adults than among the general population, and ACE exposure might be associated with prevalence of mental illness, substance misuse, and victimisation. Policy efforts and evidence-based interventions are urgently needed to prevent ACEs and address associated poor outcomes among this population.

In this paper, we examine the mental health effects of lowering the UK's benefit cap in 2016. This policy limits the total amount a household with no-one in full-time employment can receive in social security. We treat the reduction in the cap as a natural policy experiment, comparing those at risk of being capped and those who were not, and examining the risk of experiencing poor mental health both before and after the cap was lowered. Drawing on data from ~900,000 individuals, we find that the prevalence of depression or anxiety among those at risk of being capped increased by 2.6 percentage points (95% confidence interval: 1.33–3.88) compared with those at a low risk of being capped. Capping social security may increase the risk of mental ill health and could have the unintended consequence of pushing out-of-work people even further away from the labour market.

Background: Levels of child malnutrition and hunger across the world have decreased substantially over the past century, and this has had an important role in reducing mortality and improving health. However, progress has stalled. We examined whether family policies (eg, cash transfers from governments that aim to support households with children) are associated with reduced food insecurity.

Methods: In this observational analysis, we used a dataset of individual-level data that captured experience-based measures of food insecurity and sociodemographic characteristics collected by the Gallup World Poll in 142 countries for 2014–17. We then combined this dataset with indicators of the type and generosity of family policies in these countries, taken from the University of California, Los Angeles’ World Policy Analysis Center. We used multilevel regression models to examine the association between the presence of family policies for households with children and the probability of reporting moderate or severe food insecurity or severe food insecurity (moderate or severe food insecurity was defined as a “yes” response to at least four of eight questions on the Gallup Food Insecurity Experience Scale, and severe food insecurity was defined as a “yes” response to at least seven questions). We controlled for multiple covariates, including individual-level measures of social position and country-level measures, such as gross domestic product. We further examined whether this association varied by household income level.

Results: Using data from 503·713 households, we found that, on average, moderate or severe food insecurity is 4·09 percentage points (95% CI 3·50–4·68) higher in households with at least one child younger than 15 years than in households with no children and severe food insecurity is 2·20 percentage points (1·76–2·63) higher. However, the additional risk of food insecurity among households with children is lower in countries that provide financial support (either means-tested or universal) for families than for countries with little or no financial assistance. These policies not only reduce food insecurity on average, but they also reduce inequalities in food insecurity by benefiting the poorest households most.

Conclusions: In some countries, family policies have been cut back in the past decade and such retrenchment might expose low-income households to increased risk of food insecurity. By increasing investment in family policies, progress towards Sustainable Development Goal 2, zero hunger, might be accelerated and, in turn, improve health for all.

Background: Income inequality is associated with poor health when economic disparities are especially salient. Yet, political institutions may alter this relationship because democracies (as opposed to autocracies) may be more inclined to frame inequalities in negative rather than positive ways. Living in a particular political system potentially alters the messages individuals receive about whether inequality is large or small, good or bad, and this, in turn, might affect whether beliefs about inequality influence health. Further, media coverage of economic inequality may negatively affect health if it contributes toward the general perception that the gap between rich and poor has gone up, even if there has been no change in income differentials.

Methods: In this study, we explore the relationship between democracy, perceptions of inequality, and self-rated health across 28 post-communist countries using survey and macro-level data, multilevel regression models, and inverse probability weighting to estimate the average treatment effect on the treated.

Results: We find that self-rated health is higher in more democratic countries and lower among people who believe that inequality has risen in the last few years. Moreover, we observe that people in democracies are more likely to learn about rising inequality through watching television and that when they do it has a more harmful effect on their health than when people in autocracies learn about rising inequality through the same channel, suggesting that in countries where there is less trust in the television media learning about rising inequality is not as harmful for health.

Conclusions: Our results indicate that while democracies are generally good for well-being, they may not be unambiguously positive for health. This does not mean, of course, that inequality is good for health nor that, on average, autocracies have better health than democracies; but rather that being more aware of inequality can negatively affect self-rated health.

The 'omnivore' hypothesis currently dominates the academic literature on the social patterning of taste. It argues that cultural elites no longer resemble the traditional stereotype of an elitist snob. Instead, they are more likely to be ‘omnivores’ with broad tastes encompassing both elite and popular cultural forms. The omnivore hypothesis has inspired more than two decades of research and debate, without a clear resolution. In this article, we argue that progress in the omnivore debate has been impeded in part due to an elision of two distinct interpretations of the omnivore hypothesis: a strong interpretation, which holds that cultural elites are generally averse to class-based exclusivity; and a weak interpretation which holds that, while elites have broad tastes which encompass popular forms, they do not necessarily repudiate class-based exclusion. We demonstrate how drawing this distinction helps to clarify the existing empirical evidence concerning the omnivore hypothesis.

Do wage‐setting institutions, such as collective bargaining, improve health and, if so, is this because they reduce income inequality? Wage‐setting institutions are often assumed to improve health because they increase earnings and reduce inequality and yet, while individual‐level studies suggest higher earnings improve well being, the direct effects of these institutions on mortality remains unclear. This paper explores both the relationship between wage‐setting institutions and mortality rates whether income inequality mediates this relationship. Using 50 years of data from 22 high‐income countries (n ~ 825), I find mortality rates are lower in countries with collective bargaining compared to places with little or no wage protection. While wage‐setting institutions may reduce economic inequality, these institutions do not appear to improve health because they reduce inequality. Instead, collective bargaining improves health, in part, because they increase average wage growth. The political and economic drivers of inequality may not, then, be correlated with health outcomes, and, as a result, health scholars need to develop more nuanced theories of the political economy of health that are separate from but in dialogue with the political economy of inequality.

Policymakers seeking to reform social security systems have frequently confronted a central tension: how to reconcile welfare retrenchment with the political challenges of implementing unpopular reforms. One way in which policymakers have responded to this tension is by repurposing existing institutions to serve new ends. We investigate the system of Universal Credit (UC) in the United Kingdom as an example of conversion. UC expands the reach of ‘active citizenship’ policies to a much larger population than ever before. However, far from producing uniform outcomes, UC’s implementation has been marked by chaos and ultimately failure for individuals and communities. We argue that UC exemplifies a broader shift from social security to state-sanctioned social insecurity as policy reforms come to mimic the insecurities and risks commonly associated with the market.

Objectives. To examine the association between wage-setting policy and food insecurity.

Methods. We estimated multilevel regression models, using data from the Gallup World Poll (2014–2017) and UCLA’s World Policy Analysis Center, to examine the association between wage setting policy and food insecurity across 139 countries (n=492,078).

Results. Compared with countries with little or no minimum wage, the probability of being food insecure was 0.10 lower (95% confidence interval=0.02, 0.18) in countries with collective bargaining. However, these associations varied across employment status. More generous wage-setting policies (e.g., collective bargaining or high minimum wages) were associated with lower food insecurity among full-time workers (and, to some extent, part-time workers) but not those who were unemployed.

Conclusions. In countries with generous wage-setting policies, employed adults had a lower risk of food insecurity, but the risk of food insecurity for the unemployed was unchanged. Wage-setting policies may be an important intervention for addressing risks of food insecurity among low-income workers.

This article examines what role equality law can play in addressing the inequalities created and exacerbated by the British government’s response to the Covid-19 pandemic. We argue that while there is great potential in existing legislation, there is a need for both policy-makers and courts to apply a more searching and nuanced understanding of the right to equality if this potential is to be realised. We begin by examining how the burdens of confronting this pandemic as a society fall more heavily on those already at the bottom end of the scale of inequality. We then ask whether and to what extent the current legal structures protecting the right to equality can be mobilised to redress such inequalities, paying particular attention to the Public Sector Equality Duty under the Equality Act 2010 and on the Human Rights Act 1998. Finally, we argue that, to fulfil the requirements of both these legal duties, the courts should subject policies and practices to close scrutiny under the four-dimensional approach. When making and operationalising policies around Covid-19, substantive equality requires account to be taken simultaneously of the four dimensions of inequality to the greatest extent possible.

Objective To investigate how health issues affect voting behaviour by considering the COVID-19 pandemic, which offers a unique opportunity to examine this interplay.

Design We employ a survey experiment in which treatment groups are exposed to key facts about the pandemic, followed by questions intended to elicit attitudes toward the incumbent party and government responsibility for the pandemic.

Setting The survey was conducted amid the lockdown period of 15–26 April 2020 in three large democratic countries with the common governing language of English: India, the United Kingdom and the United States. Due to limitations on travel and recruitment, subjects were recruited through the M-Turk internet platform and the survey was administered entirely online. Respondents numbered 3648.

Results Our expectation was that respondents in the treatment groups would favour, or disfavour, the incumbent and assign blame to government for the pandemic compared with the control group. We observe no such results. Several reasons may be adduced for this null finding. One reason could be that public health is not viewed as a political issue. However, people do think health is an important policy area (>85% agree) and that government has some responsibility for health (>90% agree). Another reason could be that people view public health policies through partisan lenses, which means that health is largely endogenous, and yet we find little evidence of polarisation in our data. Alternatively, it could be that the global nature of the pandemic inoculated politicians from blame and yet a majority of people do think the government is to blame for the spread of the pandemic (~50% agree).

Conclusions While we cannot precisely determine the mechanisms at work, the null findings contained in this study suggest that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election.

In this paper we explore whether the recent rise in food bank usage in the UK has been induced by the roll-out of Universal Credit. We bring together official statistics on the introduction of Universal Credit with data on food bank usage from the UK’s largest food bank network. We test the relationship between Universal Credit and food parcel distribution using a range of causal identification strategies (such as fixed-effects model, Granger causality tests, and matching designs) and consistently find that an increase in the prevalence of Universal Credit is associated with more food parcel distribution. We also find that the relationship between Universal Credit and food parcel distribution is stronger in areas where food banks are active, suggesting food insecurity arising from Universal Credit may be hidden in places where food banks are largely unavailable. Though it is challenging to implement any large-scale change to social security, our analysis suggests systemic and persistent problems with this new system. Whilst the logic of Universal Credit is intuitively appealing, it has also proven to be unforgiving, leaving many struggling to make ends meet.

Background: Eradicating food insecurity is necessary for achieving global health goals. Liberal trade policies might increase food supplies but how these policies influence individual-level food insecurity remains uncertain. We aimed to assess the association between liberal trade policies and food insecurity at the individual level, and whether this association varies across country-income and household-income groups.

Methods: For this observational analysis, we combined individual-level data from the Food and Agricultural Organization of the UN with a country-level trade policy index from the Konjunkturforschungsstelle Swiss Economic Institute. We examined the association between a country's trade policy score and the probability of individuals reporting moderate-severe or severe food insecurity using regression models and algorithmic weighting procedures. We controlled for multiple covariates, including gross domestic product, democratisation level, and population size. Additionally, we examined heterogeneity by country and household income.

Results: Our sample comprised 460,102 individuals in 132 countries for the period of 2014–17. Liberal trade policy was not significantly associated with moderate-severe or severe food insecurity after covariate adjustment. However, among households in high-income countries with incomes higher than US$25,430 per person per year (adjusted for purchasing power parity), a unit increase in the trade policy index (more liberal) corresponded to a 0·07% (95% CI −0·10 to −0·04) reduction in the predicted probability of reporting moderate-severe food insecurity. Among households in the lowest income decile (<$450 per person per year) in low-income countries, a unit increase in the trade policy index was associated with a 0·35% (0·06 to 0·60) increase in the predicted probability of reporting moderate-severe food insecurity.

Interpretation: The relationship between liberal trade policy and food insecurity varied across countries and households. Liberal trade policy was predominantly associated with lower food insecurity in high-income countries but corresponded to increased food insecurity among the world's poorest households in low-income countries.

How do elites signal their superior social position via the consumption of culture? We address this question by drawing on 120 years of “recreations” data (N = 71,393) contained within Who’s Who, a unique catalogue of the British elite. Our results reveal three historical phases of elite cultural distinction: first, a mode of aristocratic practice forged around the leisure possibilities afforded by landed estates, which waned significantly in the late-nineteenth century; second, a highbrow mode dominated by the fine arts, which increased sharply in the early-twentieth century before gently receding in the most recent birth cohorts; and, third, a contemporary mode characterized by the blending of highbrow pursuits with everyday forms of cultural participation, such as spending time with family, friends, and pets. These shifts reveal changes not only in the contents of elite culture but also in the nature of elite distinction, in particular, (1) how the applicability of emulation and (mis)recognition theories has changed over time, and (2) the emergence of a contemporary mode that publicly emphasizes everyday cultural practice (to accentuate ordinariness, authenticity, and cultural connection) while retaining many tastes that continue to be (mis)recognized as legitimate.

Individuals do not possess an entirely accurate assessment of the level of income differences in their society and so changes in quantitative measures of income inequality may not always align with changes in the perceptions of income inequality. This disconnect is partly driven by how people form their opinions about the level of inequality. In this study we explore whether there is an association between perceptions of inequality and health, and if so, how it differs depending on the specific channel through which people formed their opinions about changes in income inequality. Drawing on data from 31 European and Eurasian countries, we find that both men and women are more likely to report bad health when their perceptions of increasing inequality are formed through experiences of inequality in their communities than through media and other channels.

Inequalities in health are pervasive and durable, but they are not uniform. To date, however, the drivers of these between-country patters in health inequalities remain largely unknown. In this analysis, we draw on data from 17 European countries to explore whether inequalities in political participation, that is, inequalities in voting by educational attainment, are correlated with health inequalities. Over and above a range of relevant confounders, such as GDP, income inequality, health spending, social protection spending, poverty rates, and smoking, greater inequalities in political participation remain correlated with higher health inequalities. If ‘politicians and officials are under no compulsion to pay much heed to classes and groups of citizens that do not vote’ then political inequalities could indirectly affect health through its impact on policy choices that determine who has access to the resources necessary for a healthy life. Inequalities in political participation, then, may well be one of the ‘causes of the causes’ of ill-health.

Background Rising food bank use in the past decade in the UK raises questions about whether food insecurity has increased. Using the 2016 Food and You survey, we describe the magnitude and severity of the problem, examine characteristics associated with severity of food insecurity, and examine how vulnerability has changed among low-income households by comparing 2016 data to the 2004 Low Income Diet and Nutrition Survey.

Methods The Food and You survey is a representative survey of adults living in England, Wales, and Northern Ireland (n=3118). Generalised ordered logistic regression models were used to examine how socioeconomic characteristics related to severity of food insecurity. Coarsened exact matching was used to match respondents to respondents in the 2004 survey. Logistic regression models were used to examine if food insecurity rose between survey years.

Results 20.7% (95% CI 18.7% to 22.8%) of adults experienced food insecurity in 2016, and 2.72% (95% CI 2.07% to 3.58%) were severely food insecure. Younger age, non-white ethnicity, low education, disability, unemployment, and low income were all associated with food insecurity, but only the latter three characteristics were associated with severe food insecurity. Controlling for socioeconomic variables, the probability of low-income adults being food insecure rose from 27.7% (95% CI 24.8% to 30.6 %) in 2004 to 45.8% (95% CI 41.6% to 49.9%) in 2016. The rise was most pronounced for people with disabilities.

Conclusions Food insecurity affects economically deprived groups in the UK, but unemployment, disability and low income are characteristics specifically associated with severe food insecurity. Vulnerability to food insecurity has worsened among low-income adults since 2004, particularly among those with disabilities.

Highbrow culture may not always be central to cultural capital and, in such circumstances, the distinctiveness of middle-class consumption of highbrow culture may diminish, becoming more similar to working-class patterns of highbrow consumption. Using data from 30 European countries, I explore this issue through examining three questions: 1) is class identity associated with highbrow consumption; 2) does this association vary across countries; and 3) is the relationship between class identity and highbrow consumption altered when the majority of people in a given society identify as either ‘working-class’ or ‘middle-class’? After accounting for other socio-demographic controls, people who identify as middle-class are more active highbrow consumers than those who identify as working class. Yet, the distinctiveness of middle-class consumption of highbrow culture varies across countries and is negatively correlated with how many people identify as working-class in a society. As more people identify as working-class (rejecting middle-class identities) highbrow culture less clearly distinguishes middle-class and working-class identifiers. In the absence of any class-structured divisions in highbrow culture, whether and how cultural practices function as a form of cultural capital is likely quite different, reinforcing the claim that the centrality of highbrow culture to cultural capital varies geographically.

Recessions appear to coincide with an increasingly stigmatising presentation of poverty in parts of the media. Previous research on the connection between high unemployment and media discourse has often relied on case studies of periods when stigmatising rhetoric about the poor was increasing. We build on earlier work on how economic context affects media representations of poverty by creating a unique dataset that measures how often stigmatising descriptions of the poor are used in five centrist and right-wing British newspapers between 1896 and 2000. Our results suggest stigmatising rhetoric about the poor increases when unemployment rises, except at the peak of very deep recessions (e.g. the 1930s and 1980s). This pattern is consistent with the idea that newspapers deploy deeply embedded Malthusian explanations for poverty when those ideas resonate with the economic context, and so this stigmatising rhetoric of recessions is likely to recur during future economic crises.

Sociologists have long acknowledged that being in a precarious labour market position, whether employed or unemployed, can harm peoples' health. However, scholars have yet to fully investigate the possible contextual, institutional determinants of this relationship. Two institutions that were overlooked in previous empirical studies are the regulations that set minimum compensation for dismissal, severance payments, and entitlements to a period of notice before dismissal, notice periods. These institutions may be important for workers' health as they influence the degree of insecurity that workers are exposed to. Here, we test this hypothesis by examining whether longer notice periods and greater severance payments protect the health of labour market participants, both employed and unemployed. We constructed two cohorts of panel data before and during the European recession using data from 22 countries in the European Union Statistics on Income and Living Conditions (person years = 338,000). We find more generous severance payments significantly reduce the probability that labour market participants, especially the unemployed, will experience declines in self‐reported health, with a slightly weaker relationship for longer notice periods.

In this paper, we argue that particular institutional arrangements partly explain the large and persistent differences in health systems and health outcomes observed in former colonies. Drawing on data from the World Health Organization for 62 countries, covering the period 2000–2014, we explore whether economic (risk of expropriation) and health (complete cause of death registries) institutions explain mortality rates and access to healthcare. To identify this relationship, we use settler mortality and the distance of the capital from the nearest major port – factors associated with institutional arrangements – to explain cross-national variation in health outcomes and the universality of health systems. We find that inclusive institutions arrangements – that protect and acknowledge the rights of citizens – are associated with better health outcomes (e.g. lower infant mortality and lower maternal mortality) as well as with better health systems (e.g. more skilled birth attendance and greater immunization). Inclusive institutions not only foster economic growth but improve health and well-being too.

Inequalities in infant mortality rates (IMRs) are rising in some low- and middle-income countries (LMICs) and decreasing in others, but the explanation for these divergent trends is unclear. We investigate whether government expenditures and redistribution are associated with reductions in inequalities in IMRs. We estimated country-level fixed-effects panel regressions for 48 LMICs (142 country observations). Slope and Relative Indices of Inequality in IMRs (SII and RII) were calculated from Demographic and Health Surveys between 1993 and 2013. RII and SII were regressed on government expenditure (total, health and non-health) and redistribution, controlling for gross domestic product (GDP), private health expenditures, a democracy indicator, country fixed effects and time. Mean SII and RII was 39.12 and 0.69, respectively. In multivariate models, a 1 percentage point increase in total government expenditure (% of GDP) was associated with a decrease in SII of −2.468 [95% confidence intervals (CIs): −4.190, −0.746] and RII of −0.026 (95% CIs: −0.048, −0.004). Lower inequalities were associated with higher non-health government expenditure, but not higher government health expenditure. Associations with inequalities were non-significant for GDP, government redistribution, and private health expenditure. Understanding how non-health government expenditure reduces inequalities in IMR, and why health expenditures may not, will accelerate progress towards the Sustainable Development Goals.

There are concerns that the recovery from the Great Recession in Europe has left growing numbers of people facing precarious housing situations. Yet, to our knowledge, there is no comparative measure of housing precariousness in contrast to an extensive body of work on labour market precariousness. Here, we draw on a comparative survey of 31 European countries from the 2012 wave of European Union Survey of Income and Living Conditions to develop a novel housing precariousness measure. We integrate four dimensions of housing precariousness: security, affordability, quality and access to services, into a scale ranging from 0 (not at all precarious) to 4 (most precarious). Over half of the European population report at least one element of housing precariousness; 14.7 percent report two dimensions and 2.8 percent three or more (equivalent to ~15 million people). Eastern European and small island nations have relatively greater precariousness scores. Worse precariousness tends to be more severe among the young, unemployed, single and those with low educational attainment or who live in rented homes and is associated with poor self-reported health. Future research is needed to strengthen surveillance of housing precariousness as well as to understand what policies and programmes can help alleviate it.

Cultural consumption is often viewed as a form of embodied cultural capital which can be converted into economic rewards (e.g., earnings) because such practices increase the likelihood of moving into more advantaged social positions. However, quantitative evidence supporting this theory remains uncertain because it is often unable to rule out alternative explanations. Cultural consumption appears to influence hiring decisions in some elite firms, in both the US and the UK, but it is unclear whether these processes are applicable to other professional occupations and other labour market processes, such as promotions. We examine these processes using data from Understanding Society, an individual‐level panel survey conducted in the UK, allowing us to explore whether cultural consumption predicts future earnings, upward social mobility and promotions. People who consume a larger number of cultural activities are more likely to earn higher wages in the future, to be upwardly socially mobile, and to be promoted. Cultural consumption, then, can function as cultural capital in some labour market settings, potentially contributing to the reproduction of income inequality between generations.

Since 2009, the UK has witnessed marked increases in the rate of sanctions applied to unemployment insurance claimants, as part of a wider agenda of austerity and welfare reform. In 2013, over one million sanctions were applied, stopping benefit payments for a minimum of four weeks and potentially leaving people facing economic hardship and driving them to use food banks. Here we explore whether sanctioning is associated with food bank use by linking data from The Trussell Trust Foodbank Network with records on sanctioning rates across 259 local authorities in the UK. After accounting for local authority differences and time trends, the rate of adults fed by food banks rose by an additional 3.36 adults per 100,000 (95% CI: 1.71 to 5.01) as the rate of sanctioning increased by 10 per 100,000 adults. The availability of food distribution sites affected how tightly sanctioning and food bank usage were associated (p < 0.001); in areas with few distribution sites, rising sanctions led to smaller increases in food bank usage. In conclusion, sanctioning is closely linked with rising food bank usage, but the impact of sanctioning on household food insecurity is not fully reflected in available data.

Background Unmet medical need (UMN) had been declining steadily across Europe until the 2008 Recession, a period characterized by rising unemployment. We examined whether becoming unemployed increased the risk of UMN during the Great Recession and whether the extent of out-of-pocket payments (OOP) for health care and income replacement for the unemployed (IRU) moderated this relationship.

Methods We used the European Survey on Income and Living Conditions (EU-SILC) to construct a pseudo-panel (n=135 529) across 25 countries to estimate the relationship between unemployment and UMN. We estimated linear probability models, using a baseline of employed people with no UMN, to test whether this relationship is mediated by financial hardship and moderated by levels of OOP and IRU.

Results Job loss increased the risk of UMN [β=0.027, 95% confidence interval (CI) 0.022–0.033] and financial hardship exacerbated this effect. Fewer people experiencing job loss lost access to health care in countries where OOPs were low or in countries where IRU is high. The results are robust to different model specifications.

Conclusions Unemployment does not necessarily compromise access to health care. Rather, access is jeopardized by diminishing financial resources that accompany job loss. Lower OOPs or higher IRU protect against loss of access, but they cannot guarantee it. Policy solutions should secure financial protection for the unemployed so that resources do not have to be diverted from health.

We draw on 120 years of biographical data (N = 120,764) contained within Who’s Who—a unique catalogue of the British elite—to explore the changing relationship between elite schools and elite recruitment. We find that the propulsive power of Britain’s public schools has diminished significantly over time. This is driven in part by the wane of military and religious elites, and the rise of women in the labor force. However, the most dramatic declines followed key educational reforms that increased access to the credentials needed to access elite trajectories, while also standardizing and differentiating them. Notwithstanding these changes, public schools remain extraordinarily powerful channels of elite formation. Even today, the alumni of the nine Clarendon schools are 94 times more likely to reach the British elite than are those who attended any other school. Alumni of elite schools also retain a striking capacity to enter the elite even without passing through other prestigious institutions, such as Oxford, Cambridge, or private members clubs. Our analysis not only points to the dogged persistence of the “old boy,” but also underlines the theoretical importance of reviving and refining the study of elite recruitment.

Living with housing problems increases the risk of mental ill health. Housing problems tend to persist over time but little is known about the mental health consequences of living with persistent housing problems. We investigated if persistence of poor housing affects mental health over and above the effect of current housing conditions. We used data from 13 annual waves of the British Household Panel Survey (1996 to 2008) (81,745 person/year observations from 16,234 individuals) and measured the persistence of housing problems by the number of years in the previous four that a household experienced housing problems. OLS regression models and lagged-change regression models were used to estimate the effects of past and current housing conditions on mental health, as measured by the General Health Questionnaire. Interaction terms tested if tenure type modified the impact of persistent poor housing on mental health. In fully adjusted models, mental health worsened as the persistence of housing problems increased. Adjustment for current housing conditions attenuated, but did not explain, the findings. Tenure type moderated the effects of persistent poor housing on mental health, suggesting that those who own their homes outright and those who live in social housing are most negatively affected. Persistence of poor housing was predictive of worse mental health, irrespective of current housing conditions, which added to the weight of evidence that demonstrates that living in poor quality housing for extended periods of time has negative consequences for mental health.

Objectives Persons engaged in the sex industry are at greater risk of HIV and other sexually transmitted infections than the general population. One major factor is exposure to higher levels of risky sexual activity. Expanding condom use is a critical prevention strategy, but this requires negotiation with those buying sex, which takes place in the context of cultural and economic constraints. Impoverished individuals who fear violence are more likely to forego condoms.

Methods Here we tested the hypotheses that poverty and fear of violence are two structural drivers of HIV infection risk in the sex industry. Using data from the European Centre for Disease Prevention and Control and the World Bank for 30 countries, we evaluated poverty, measured using the average income per day per person in the bottom 40% of the income distribution, and gender violence, measured using homicide rates in women and the proportion of women exposed to violence in the last 12 months and/or since age 16 years.

Results We found that HIV prevalence among those in the sex industry was higher in countries where there were greater female homicide rates (β = 0.86; P = 0.018) and there was some evidence that self‐reported exposure to violence was also associated with higher HIV prevalence (β = 1.37; P = 0.043). Conversely, HIV prevalence was lower in countries where average incomes among the poorest were greater (β = −1.05; P = 0.046).

Conclusions Our results are consistent with the theory that reducing poverty and exposure to violence may help reduce HIV infection risk among persons engaged in the sex industry.

Background Economic insecurity correlates with adverse health outcomes, but the biological pathways involved are not well understood. We examine how changes in economic insecurity relate to metabolic, inflammatory and liver function biomarkers.

Methods Blood analyte data were taken from 6520 individuals (aged 25–59 years) participating in Understanding Society. Economic insecurity was measured using an indicator of subjective financial strain and by asking participants whether they had missed any bill, council tax, rent or mortgage payments in the past year. We investigated longitudinal changes in economic insecurity (remained secure, increase in economic insecurity, decrease in economic insecurity, remained insecure) and the accumulation of economic insecurity. Linear regression models were calculated for nine (logged) biomarker outcomes related to metabolic, inflammatory, liver and kidney function (as falsification tests), adjusting for potential confounders.

Results Compared with those who remained economically stable, people who experienced consistent economic insecurity (using both measures) had worsened levels of high-density lipoprotein (HDL)-cholesterol, triglycerides, C reactive protein (CRP), fibrinogen and glycated haemoglobin. Increased economic insecurity was associated with adverse levels of HDL-cholesterol (0.955, 95% CI 0.929 to 0.982), triglycerides (1.077, 95% CI 1.018 to 1.139) and CRP (1.114, 95% CI 1.012 to 1.227), using the measure of financial strain. Results for the other measure were generally consistent, apart from the higher levels of gamma-glutamyl transferase observed among those experiencing persistent insecurity (1.200, 95% CI 1.110 to 1.297).

Conclusion Economic insecurity is associated with adverse metabolic and inflammatory biomarkers (particularly HDL-cholesterol, triglycerides and CRP), heightening risk for a range of health conditions.

Imposing financial penalties on claimants of unemployment insurance may incentivise labour market re-entry. However, sanctions may have differential effects depending on the work-readiness of the claimants. Here, I explore whether sanctioning disabled claimants is associated with greater labour market activity or inactivity among disabled people data on 346 British local authorities between 2009 and 2014. When the number of sanctioned disabled claimants rises (as a proportion of all claimants), the disability rate among economically inactive people becomes larger. There is no clear relationship between sanctioning disabled claimants and the employed disability rate.

Background It is not clear whether the harm associated with smoking differs by socioeconomic status. This study tests the hypothesis that smoking confers a greater mortality risk for individuals in low socioeconomic groups, using a cohort of 18 479 adults drawn from the English Longitudinal Study of Ageing.

Methods:- Additive hazards models were used to estimate the absolute smoking-related risk of death due to lung cancer or Chronic Obstructive Pulmonary Disease (COPD). Smoking was measured using a continuous index that incorporated the duration of smoking, intensity of smoking and the time since cessation. Attributable death rates were reported for different levels of education, occupational class, income and wealth.

Results Smoking was associated with higher absolute mortality risk in lower socioeconomic groups for all four socioeconomic indicators. For example, smoking 20 cigarettes per day for 40 years was associated with 898 (95% CI 738, 1058) deaths due to lung cancer or COPD per 100 000 person-years among participants in the bottom income tertile, compared to 327 (95% CI 209, 445) among participants in the top tertile.

Conclusions Smoking is associated with greater absolute mortality risk for individuals in lower socioeconomic groups. This suggests greater public health benefits of smoking prevention or cessation in these groups.

Objective Food insecurity has been rising across Europe following the Great Recession, but to varying degrees across countries and over time. The reasons for this increase are not well understood, nor are what factors might protect people’s access to food. Here we test the hypothesis that an emerging gap between food prices and wages can explain increases in reported inability to afford protein-rich foods and whether welfare regimes can mitigate its impact.

Design We collected data in twenty-one countries from 2004 to 2012 using two databases: (i) on food prices and deprivation related to food (denoted by reported inability to afford to eat meat, chicken, fish or a vegetarian equivalent every second day) from EuroStat 2015 edition; and (ii) on wages from the Organisation for Economic Co-operation and Development 2015 edition.

Results After adjusting for macroeconomic factors, we found that each 1 % rise in the price of food over and above wages was associated with greater self-reported food deprivation (β=0·060, 95 % CI 0·030, 0·090), particularly among impoverished groups. However, this association also varied across welfare regimes. In Eastern European welfare regimes, a 1 % rise in the price of food over wages was associated with a 0·076 percentage point rise in food deprivation (95 % CI 0·047, 0·105) while in Social Democratic welfare regimes we found no clear association (P=0·864).

Conclusions Rising prices of food coupled with stagnating wages are a major factor driving food deprivation, especially in deprived groups; however, our evidence indicates that more generous welfare systems can mitigate this impact.

In recent years, health behaviour interventions have received a great deal of attention in both research and policy as a means of encouraging people to lead healthier lives. The emphasis of such interventions has varied over time, in terms of level of intervention (e.g. individual vs community) and drawing on different disciplinary perspectives. Recently, a number of critiques have focused on how health behaviour interventions sometimes sideline issues of social context, framing health as a matter of individual choice and, by implication, a personal responsibility. Part of this criticism is that health behaviour interventions often do not draw on alternative social science understandings of the structured and contextual aspects of behaviour and health. Yet to our knowledge, no study has attempted to empirically assess the extent to which, and in what ways, the health behaviour intervention field has paid attention to social context. In this article, we undertake this task using bibliometric techniques in order to map out the health behaviour intervention field. We find that the number of health behaviour interventions has grown rapidly in recent years, especially since around 2006, and that references to social science disciplines and concepts that foreground issues of social context are rare and, relatively speaking, constitute less of the field post 2006. More quantifiable concepts are used most, and those more close to the complexities of social context are mentioned least. The document co-citation analysis suggests that pre 2006, documents referring to social context were relatively diffuse in the network of key citations, but post 2006 this influence had largely diminished. The journal co-citation analysis shows less disciplinary overlap post 2006. At present, health behaviour interventions are continuing to focus on individualised approaches drawn from behavioural psychology and behavioural economics. Our findings lend empirical support to a number of recent papers that suggest more interdisciplinary collaboration is needed to advance the field.

Background Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers.

Method We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department's Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers.

Findings Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=–2·09, 95% CI −0·80 to −3·37; p=0·003), even after controlling for the level of economic development (β=–1·86; p=0·038) and the proportion of sex workers who are injecting drug users (−1·93; p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective.

Interpretation Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair.

Underpinned by the assumption that unemployed persons are passive recipients of social security, recent welfare reforms have increased benefit conditionality in the UK and introduced harsher penalties for failure to meet these conditions. Yet, conditionality may result in vulnerable groups disproportionately experiencing disentitlement from benefits, one of the rights of social citizenship, because they are, in some cases, less able to meet these conditions. Rising sanctions, then, may be the product of a disconnection between welfare conditionality and the capabilities of vulnerable claimants. To test this hypothesis, we evaluate whether sanctions are higher in areas where there are more vulnerable Jobseeker's Allowance claimants, namely, lone parents, ethnic minorities and those with disabilities. We find that sanction rates are higher in local authorities where more claimants are lone parents or live with a disability, and that this relationship has strengthened since the welfare reforms were introduced under the Conservative-led coalition. Failure to meet conditions of benefit receipt may disproportionately affect vulnerable groups.

The post-war period in Europe, between the late 1940s and the 1970s, was characterised by an expansion of the role of by the state, protecting its citizens from risks of unemployment, poverty, homelessness, and food insecurity. This security began to erode in the 1980s as a result of privatisation and deregulation. The withdrawal of the state further accelerated after the 2008 financial crisis, as countries began pursuing deep austerity. The result has been a rise in what has been termed ‘precariousness’. Here we review the development of the concept of precariousness and related phenomena of vulnerability and resilience, before reviewing evidence of growing precariousness in European countries. It describes a series of studies of the impact on precariousness on health in domains of employment, housing, and food, as well as natural experiments of policies that either alleviate or worsen these impacts. It concludes with a warning, drawn from the history of the 1930s, of the political consequences of increasing precariousness in Europe and North America.

Background Since the onset of the Great Recession in Europe, unmet need for medical care has been increasing, especially in persons aged 65 or older. It is possible that public pensions buffer access to healthcare in older persons during times of economic crisis, but to our knowledge, this has not been tested empirically in Europe.

Methods We integrated panel data on 16 European countries for years 2004–2010 with indicators of public pension, unemployment insurance and sickness insurance entitlement from the Comparative Welfare Entitlements Dataset and unmet need (due to cost) prevalence rates from EuroStat 2014 edition. Using country-level fixed-effects regression models, we evaluate whether greater public pension entitlement, which helps reduce old-age poverty, reduces the prevalence of unmet medical need in older persons and whether it reduces inequalities in unmet medical need across the income distribution.

Results We found that each 1-unit increase in public pension entitlement is associated with a 1.11 percentage-point decline in unmet medical need due to cost among over 65s (95% CI −0.55 to −1.66). This association is strongest for the lowest income quintile (1.65 percentage points, 95% CI −1.19 to −2.10). Importantly, we found consistent evidence that out-of-pocket payments were linked with greater unmet needs, but that this association was mitigated by greater public pension entitlement (β=−1.21 percentage points, 95% CI −0.37 to −2.06).

Conclusions Greater public pension entitlement plays a crucial role in reducing inequalities in unmet medical need among older persons, especially in healthcare systems which rely heavily on out-of-pocket payments.

There has been extensive outsourcing of hospital cleaning services in the NHS in England, in part because of the potential to reduce costs. Yet some argue that this leads to lower hygiene standards and more infections, such as MRSA and, perhaps because of this, the Scottish, Welsh, and Northern Irish health services have rejected outsourcing. This study evaluates whether contracting out cleaning services in English acute hospital Trusts (legal authorities that run one or more hospitals) is associated with risks of hospital-borne MRSA infection and lower economic costs. By linking data on MRSA incidence per 100,000 hospital bed-days with surveys of cleanliness among patient and staff in 126 English acute hospital Trusts during 2010–2014, we find that outsourcing cleaning services was associated with greater incidence of MRSA, fewer cleaning staff per hospital bed, worse patient perceptions of cleanliness and staff perceptions of availability of handwashing facilities. However, outsourcing was also associated with lower economic costs (without accounting for additional costs associated with treatment of hospital acquired infections).

Housing security is an important determinant of mental ill health. We used a quasinatural experiment to evaluate this association, comparing the prevalence of mental ill health in the United Kingdom before and after the government's April 2011 reduction in financial support for low-income persons who rent private-sector housing (mean reduction of approximately £1,220 ($2,315) per year). Data came from the United Kingdom's Annual Population Survey, a repeated quarterly cross-sectional survey. We focused our analysis on renters in the private sector, disaggregating data between an intervention group receiving the government's Housing Benefit (n = 36,859) and a control group not receiving the Housing Benefit (n = 142,205). The main outcome was a binary measure of self-reported mental health problems. After controlling for preexisting time trends, we observed that between April 2011 and March 2013, the prevalence of depressive symptoms among private renters receiving the Housing Benefit increased by 1.8 percentage points (95% confidence interval: 1.0, 2.7) compared with those not receiving the Housing Benefit. Our models estimated that approximately 26,000 (95% confidence interval: 14,000, 38,000) people newly experienced depressive symptoms in association with the cuts to the Housing Benefit. We conclude that reducing housing support to low-income persons in the private rental sector increased the prevalence of depressive symptoms in the United Kingdom.

Patterns of cultural consumption have a strong social gradient which is primarily driven by education, but what explains these educational differences in cultural preferences remains unclear. Explanations based on information processing capacity have gained widespread currency; the perceived cognitive ‘difficulty’ of both appreciating high culture, and of maintaining broad, omnivorous tastes. If, on average, high culture is more complex than low culture then a higher level of information processing capacity may be required to derive enjoyment from it. In contrast, socialization theories suggest that exposure to ‘high’ culture, may explain this gradient, particularly among university graduates with degrees in the Arts or Humanities. To test these two theories we use the Cultural Capital and Social Exclusion survey (n = 1,079) and estimate the association between degree type and measures of cultural preference and consumption, including: film directors, artists, and cultural participation. Compared to non‐graduates, arts, humanities, and social science graduates are more likely to enjoy highbrow directors and artists, and are more likely to be cultural omnivores; while graduates from other subjects are not clearly distinct from non‐graduates in their cultural preferences. These findings suggest that information processing plays a minor role in shaping the social gradient in cultural consumption.

Background: In 2005, India launched the National Rural Health Mission (NRHM) to strengthen the primary healthcare system. NRHM also aims to encourage pregnant women, particularly of low socioeconomic backgrounds, to use institutional maternal healthcare. We evaluated the impacts of NRHM on socioeconomic inequities in the uptake of institutional delivery and antenatal care (ANC) across high-focus (deprived) Indian states.

Methods: Data from District Level Household and Facility Surveys (DLHS) Rounds 1 (1995–99) and 2 (2000–04) from the pre-NRHM period, and Round 3 (2007–08), Round 4 and Annual Health Survey (2011–12) from post-NRHM period were used. Wealth-related and education-related relative indexes of inequality, and pre-post difference-in-differences models for wealth and education tertiles, adjusted for maternal age, rural-urban, caste, parity and state-level fixed effects, were estimated.

Results: Inequities in institutional delivery declined between pre-NRHM Period 1 (1995–99) and pre-NRHM Period 2 (2000–04), but thereafter demonstrated steeper decline in post-NRHM periods. Uptake of institutional delivery increased among all socioeconomic groups, with (1) greater effects among the lowest and middle wealth and education tertiles than highest tertile, and (2) larger equity impacts in the late post-NRHM period 2011–12 than in the early post-NRHM period 2007–08. No positive impact on the uptake of ANC was found in the early post-NRHM period 2007–08; however, there was considerable increase in the uptake of, and decline in inequity, in uptake of ANC in most states in the late post-NRHM period 2011–12.

Conclusion: In high-focus states, NRHM resulted in increased uptake of maternal healthcare, and decline in its socioeconomic inequity. Our study suggests that public health programs in developing country settings will have larger equity impacts after its almost full implementation and widest outreach. Targeting deprived populations and designing public health programs by linking maternal and child healthcare components are critical for universal access to healthcare.

Objective To determine whether sugar industry-related organizations influenced textual changes between the draft and final versions of the World Health Organization’s (WHO’s) 2015 guideline Sugars intake for adults and children.

Methods Stakeholder consultation submissions on the draft guideline from seven sugar industry-related and 10 public health organizations were assessed using the Wordscores program. Document scores were rescaled using the Martin–Vanberg transformation to improve comparability. Draft and final guidelines were compared to identify changes influenced by the sugar industry and public health organizations.

Findings There was a small shift in transformed Wordscores score between the draft and final guidelines, from 0.25 to 0.24, towards the industry position. The change was linked to increased use of the word “low” to describe the quality of the evidence, consistent with industry arguments. There was also a shift from use of the word “consumption” to “intake”, irrespective of policy position. Scores for World Sugar Research Organisation and Sugar Nutrition UK submissions (0.11 and 0.18, respectively) represented strong pro-industry positions and scores for European Public Health Alliance and Wemos submissions (1.00 and 0.88, respectively) represented the strongest public health positions. Industry tactics included challenging the quality of the evidence, distinguishing between different types of sugar and advocating harm reduction.

Conclusion There was little change between draft and final versions of the WHO sugars intake guideline 2015, following industry consultation. The main change was linked to emphasizing the low quality of the evidence on sugar’s adverse effects. Guideline development appeared relatively resistant to industry influence at the stakeholder consultation stage.

Background: Tobacco smoking harms health, so why do people smoke and fail to quit? An explanation originating in behavioural economics suggests a role for time-discounting, which describes how the value of a reward, such as better health, decreases with delay to its receipt. A large number of studies test the relationship of time-discounting with tobacco outcomes but the temporal pattern of this relationship and its variation according to measurement methods remain unclear. We review the association between time-discounting and smoking across (i) the life course, from initiation to cessation, and (ii) diverse discount measures.

Methods: We identified 69 relevant studies in Web of Science and PubMed. We synthesized findings across methodologies and evaluated discount measures, study quality and cross-disciplinary fertilization.

Results: In 44 out of 54 studies, smokers more greatly discounted the future than non-smokers and, in longitudinal studies, higher discounting predicted future smoking. Smokers with lower time-discount rates achieved higher quit rates. Findings were consistent across studies measuring discount rates using hypothetical monetary or cigarette reward scenarios. The methodological quality of the majority of studies was rated as 'moderate' and co-citation analysis revealed an isolation of economics journals and a dearth of studies in public health.

Conclusion: There is moderate yet consistent evidence that high time-discounting is a risk factor for smoking and unsuccessful cessation. Policy scenarios assuming a flat rate of population discounting may inadequately capture smokers' perceptions of costs and benefits.

Although the recent Great Recession had its origins in the housing sector, the short-term health impact of the housing crisis is not well understood. We used longitudinal data to evaluate the impact of housing payment problems on health status among home-owners and renters in 27 European states. Multi-level and fixed-effects models were applied to a retrospective cohort drawn from the EU Statistics on Income and Living Conditions survey of employed persons, comprising those without housing arrears in the base year 2008 and followed through to 2010 (n=45,457 persons, 136,371 person-years). Multi-variate models tested the impact of transitioning into housing payment arrears on self-reported health (0-worst to 4-best), adjusting for confounders including age, sex, baseline health, and individual fixed effects. Transitioning into housing arrears was associated with a significant deterioration in the health of renters (−0.09 units, 95% CI −0.05 to −0.13), but not owners (0.00, 95% CI −0.05 to 0.06), after adjusting for individual fixed effects. This effect was independent of and greater than the impact of job loss for the full sample (−0.05, 95% CI −0.002 to −0.09). The magnitude of this association varied across countries; the largest adverse associations were observed for renters in Belgium, Austria, and Italy. There was no observed protective association of differing categories of social protection or of the housing regulatory structure for renters. Women aged 30 and over who rented appeared to have worse self-reported health when transitioning into arrears than other groups. Renters also fared worse in those countries where house prices were escalating. We therefore find that housing payment problems are a significant risk factor for worse-self reported health in persons who are renting their homes. Future research is needed to understand potential sources of health resilience among renters, especially at a time when housing prices are rising in many European states.

Following the shooting of Mark Duggan by police on 4 August 2011, there were riots in many large cities in the UK. As the rioting was widely perceived to be perpetrated by the urban poor, links were quickly made with Britain's welfare policies. In this paper, we examine whether the riots, and the subsequent media coverage, influenced attitudes toward welfare recipients. Using the British Social Attitudes survey, we use multivariate difference‐in‐differences regression models to compare attitudes toward welfare recipients among those interviewed before (pre‐intervention: i.e. prior to 6 August) and after (post‐intervention: 10 August–10 September) the riots occurred (N=3,311). We use variation in exposure to the media coverage to test theories of media persuasion in the context of attitudes toward welfare recipients. Before the riots, there were no significant differences between newspaper readers and non‐readers in their attitudes towards welfare recipients. However, after the riots, attitudes diverged. Newspaper readers became more likely than non‐readers to believe that those on welfare did not really deserve help, that the unemployed could find a job if they wanted to and that those on the dole were being dishonest in claiming benefits. Although the divergence was clearest between right‐leaning newspaper and non‐newspaper readers, we do not a find statistically significant difference between right‐ and left‐leaning newspapers. These results suggest that media coverage of the riots influenced attitudes towards welfare recipients; specifically, newspaper coverage of the riots increased the likelihood that readers of the print media expressed negative attitudes towards welfare recipients when compared with the rest of the population.

There is an increasing policy commitment to address the avoidable burdens of unhealthy diet, overweight and obesity. However, to design effective policies, it is important to understand why people make unhealthy dietary choices. Research from behavioural economics suggests a critical role for time discounting, which describes how people's value of a reward, such as better health, decreases with delay to its receipt. We systematically reviewed the literature on the relationship of time discounting with unhealthy diets, overweight and obesity in Web of Science and PubMed. We identified 41 studies that met our inclusion criteria as they examined the association between time discount rates and (i) unhealthy food consumption; (ii) overweight and (iii) response to dietary and weight loss interventions. Nineteen out of 25 cross‐sectional studies found time discount rates positively associated with overweight, obesity and unhealthy diets. Experimental studies indicated that lower time discounting was associated with greater weight loss. Findings varied by how time discount rates were measured; stronger results were observed for food than monetary‐based measurements. Network co‐citation analysis revealed a concentration of research in nutrition journals. Overall, there is moderate evidence that high time discounting is a significant risk factor for unhealthy diets, overweight and obesity and may serve as an important target for intervention.

Background: Many EU nations experienced a significant housing crisis during the Great Recession of 2008–10. We evaluated the consequences of housing payment problems for people’s self-reported overall health.

Methods: We used longitudinal data from the EU Statistics on Income and Living Conditions survey covering 27 countries from 2008 to 2010 to follow a baseline sample of persons who did not have housing debt and who were employed (45 457 persons, 136 371 person–years). Multivariate linear regression and multilevel models were used to evaluate the impact of transitions into housing arrears on self-reported health, correcting for the presence of chronic illness, health limitations, and other potential socio-demographic confounders.

Results: Persons who transitioned into housing arrears experienced a significant deterioration in self-reported overall health by − 0.03 U (95% CI − 0.01 to − 0.04), even after correcting for chronic illness, disposable income and employment status, and individual fixed effects. This association was independent and similar in magnitude to that for job loss (−0.02, 95% CI: −0.01 to − 0.04). We also found that the impact of housing arrears was significantly worse among renters, corresponding to a mean 0.11 unit additional drop in health as compared with owner-occupiers. These adverse associations were only evident in persons below the 75th percentile of disposable income.

Discussion: Our analysis demonstrates that persons who suffer housing arrears experience increased risk of worsening self-reported health, especially among those who rent. Future research is needed to understand the role of alternative housing support systems and available strategies for preventing the health consequences of housing insecurity.

Food insecurity rose sharply in Europe after 2009, but marked variation exists across countries and over time. We test whether social protection programs protected people from food insecurity arising from economic hardship across Europe. Data on household food insecurity covering 21 EU countries from 2004 to 2012 were taken from Eurostat 2015 edition and the Organisation for Economic Cooperation and Development. Cross-national first difference models were used to evaluate how rising unemployment and declining wages related to changes in the prevalence of food insecurity and the role of social protection expenditure in modifying observed effects. Economic hardship was strongly associated with greater food insecurity. Each 1 percentage point rise in unemployment rates was associated with an estimated 0.29 percentage point rise in food insecurity (95% CI: 0.10 to 0.49). Similarly, each $1000 decreases in annual average wages was associated with a 0.62 percentage point increase in food insecurity (95% CI: 0.27 to 0.97). Greater social protection spending mitigated these risks. Each $1000 spent per capita reduced the associations of rising unemployment and declining wages with food insecurity by 0.05 percentage points (95% CI: − 0.10 to − 0.0007) and 0.10 (95% CI: − 0.18 to − 0.006), respectively. The estimated effects of economic hardship on food insecurity became insignificant when countries spent more than $10,000 per capita on social protection. Rising unemployment and falling wages are strong statistical determinants of increasing food insecurity, but at high levels of social protection, these associations could be prevented.

Does increasing incomes improve health? In 1999, the UK government implemented minimum wage legislation, increasing hourly wages to at least £3.60. This policy experiment created intervention and control groups that can be used to assess the effects of increasing wages on health. Longitudinal data were taken from the British Household Panel Survey. We compared the health effects of higher wages on recipients of the minimum wage with otherwise similar persons who were likely unaffected because (1) their wages were between 100 and 110% of the eligibility threshold or (2) their firms did not increase wages to meet the threshold. We assessed the probability of mental ill health using the 12‐item General Health Questionnaire. We also assessed changes in smoking, blood pressure, as well as hearing ability (control condition). The intervention group, whose wages rose above the minimum wage, experienced lower probability of mental ill health compared with both control group 1 and control group 2. This improvement represents 0.37 of a standard deviation, comparable with the effect of antidepressants (0.39 of a standard deviation) on depressive symptoms. The intervention group experienced no change in blood pressure, hearing ability, or smoking. Increasing wages significantly improves mental health by reducing financial strain in low‐wage workers.

Economic hardship accompanying large recessions can lead families to terminate unplanned pregnancies. To assess whether abortions have risen during the recession, we collected crude abortion data from 2000 to 2012 from Eurostat for countries that had legal abortions and complete data. Declining trends in abortion ratios between 2000 and 2009 have been reversing. Excess abortions between 2010 and 2012 totaled 10.6 abortions per 1000 pregnancies ending in abortion or birth or 6701 additional abortions (95% CI 1190–9240) with stronger effects in younger ages. Economic shocks may increase recourse to abortion. Further research should explore causal pathways and protective factors.

Do print media significantly impact political attitudes and party identification? To examine this question, we draw on a rare quasi-natural experiment that occurred when The Sun, a right-leaning UK tabloid, shifted its support to the Labour party in 1997 and back to the Conservative party in 2010. We compared changes in party identification and political attitudes among Sun readers with non-readers and other newspaper readerships. We find that The Sun's endorsements were associated with a significant increase in readers' support for Labour in 1997, approximately 525,000 votes, and its switch back was associated with about 550,000 extra votes for the Conservatives in 2010. Although we observed changes in readers' party preference, there was no effect on underlying political preferences. The magnitude of these changes, about 2% of the popular vote, would have been unable to alter the outcome of the 1997 General Election, but may have affected the 2010 Election.

Durkheim conceived of suicide as a product of social integration and regulation. Although the sociology of suicide has focused on the role of disintegration, to our knowledge, the interaction between integration and regulation has yet to be empirically evaluated. In this article we test whether more egalitarian gender norms, an important form of macro-regulation, protects men and women against suicidality during economic shocks. Using cross-national data covering 20 European Union countries from the years 1991 to 2011, including the recent economic crises in Europe, we first assessed the relation between unemployment and suicide. Then we evaluated potential effect modification using three measures of gender equality, the gender ratio in labour force participation, the gender pay gap, and women’s representation in parliament using multiple measures. We found no evidence of a significant, direct link between greater gender equality and suicide rates in either men or women. However, a greater degree of gender equality helped protect against suicidality associated with economic shocks. At relatively high levels of gender equality in Europe, such as those seen in Sweden and Austria, the relationship between rising unemployment rates and suicide in men disappeared altogether. Our findings suggest that more egalitarian forms of gender regulation may help buffer the suicidal consequences of economic shocks, especially in men.

Background Many governments have introduced tougher eligibility assessments for out-of-work disability benefits, to reduce rising benefit caseloads. The UK government initiated a programme in 2010 to reassess all existing disability benefit claimants using a new functional checklist. We investigated whether this policy led to more people out-of-work with long-standing health problems entering employment.

Method We use longitudinal data from the Labour Force Survey linked to data indicating the proportion of the population experiencing a reassessment in each of 149 upper tier local authorities in England between 2010 and 2013. Regression models were used to investigate whether the proportion of the population undergoing reassessment in each area was independently associated with the chances that people out-of-work with a long-standing health problem entered employment and transitions between inactivity and unemployment. We analysed whether any effects differed between people whose main health problem was mental rather than physical.

Results There was no significant association between the reassessment process and the chances that people out-of-work with a long-standing illness entered employment. The process was significantly associated with an increase in the chances that people with mental illnesses moved from inactivity into unemployment (HR=1.22, 95% CI 1.03 to 1.45).

Conclusions The reassessment policy appears to have shifted people with mental health problems from inactivity into unemployment, but there was no evidence that it had increased their chances of employment. There is an urgent need for services that can support the increasing number of people with mental health problems on unemployment benefits.

Do people change their cultural preferences in social interactions where social class is particularly salient? It remains unclear whether cultural preferences vary across interactions or whether they are stable over time. We argue that individuals may alter their cultural preferences over time and that this will be influenced by both the specifics of a particular social interaction and the ‘cultural politics of class’ in which that interaction is embedded. Using a lab-based split-ballot experiment in a research university in the East of England (n = 300), we examine preferences towards music genres depending on whether respondents are assigned to one of three experimental conditions: (1) a vignette describing someone who is working class, (2) a vignette describing someone who is middle class or (3) no vignette. Those born in the UK alter the strength of their preferences towards highbrow music genres when social class is made more salient. When the salience of class is increased it also activates particular cultural stereotypes and these stereotypes influence the strength of respondents’ preferences towards highbrow music genres. This mechanism suggests that individuals use cultural stereotypes in social interaction to position themselves and others in the social hierarchy through cultural preferences.

Background In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit had their eligibility reassessed using a new functional checklist—the Work Capability Assessment. Doctors and disability rights organisations have raised concerns that this has had an adverse effect on the mental health of claimants, but there are no population level studies exploring the health effects of this or similar policies.

Method We used multivariable regression to investigate whether variation in the trend in reassessments in each of 149 local authorities in England was associated with differences in local trends in suicides, self-reported mental health problems and antidepressant prescribing rates, while adjusting for baseline conditions and trends in other factors known to influence mental ill-health.

Results Each additional 10,000 people reassessed in each area was associated with an additional 6 suicides (95% CI 2 to 9), 2700 cases of reported mental health problems (95% CI 548 to 4840), and the prescribing of an additional 7020 antidepressant items (95% CI 3930 to 10100). The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities.

Conclusions The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. This policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

Background Trade and investment liberalization may facilitate the spread of sugar-sweetened carbonated beverages (SSCBs), products associated with increased risk factors for obesity, type II diabetes, and cardiovascular diseases (Circulation 121:1356–1364, 2010). Apart from a limited set of comparative cross-national studies, the majority of analyses linking liberalization and the food environment have drawn on case studies and descriptive accounts. The current failure of many countries to reverse the obesity epidemic calls for investigation into both individual and systemic factors, including trade and investment policies.

Methods Using a natural experimental design we tested whether Vietnam’s removal of restrictions on foreign direct investment (FDI) subsequent to its accession to the World Trade Organization in 2007 increased sales of SSCBs compared with a matched country, the Philippines, which acceded in 1995. Difference-in-difference (DID) models were used to test pre/post differences in total SSCB sales and foreign company penetration covering the years 1999–2013.

Results Following Vietnam’s removal of restrictions on FDI, the growth rate of SSCB sales increased to 12.1 % per capita per year from a prior growth rate of 3.3 %. SSCB sales per capita rose significantly faster pre- and post-intervention in Vietnam compared with the control country the Philippines (DID: 4.6 L per annum, 95 % CI: 3.8 to 5.4 L, p < 0.008). Vietnam’s increase in SSCBs was primarily attributable to products manufactured by foreign companies, whose annual sales growth rates rose from 6.7 to 23.1 %, again unmatched within the Philippines over this period (DID: 12.3 %, 95 % CI: 8.6 to 16.0 %, p < 0.049).

Conclusions Growth of SSCB sales in Vietnam, led by foreign-owned companies, significantly accelerated after trade and investment liberalization.

While parental encouragement or parent-led consumption transmits cultural practices from parents to children, the reasons parents provide regarding why they encourage cultural engagement remains unclear. Using music as a case study, and through analysing semi-structured interviews, this research explores how parents express and actualise their desire for their children to learn to play a musical instrument. Results suggest that respondents do not strongly associate musical practice with developing valued character traits nor with social or educational attainment. Instead, parental encouragement to play music is shaped by family ties and the parental perception of ‘natural’ talent in their children. Parental perception of natural talent is most common among parents who themselves play an instrument and among those parents who play music with their children. Family and musicality are the most commonly cited reasons for encouraging music and these are found among all educational groups. Without dismissing the importance of social position, this evidence suggests that parents articulate their preferences toward musical participation in terms of familial cohesion and shared identity.

Background It is unclear why rates of homelessness claims in England have risen since 2010. We used variations in rates across local authorities to test the impact of economic downturns and budget cuts.

Methods Using cross-area fixed effects models of data from 323 UK local authorities between 2004 and 2012, we evaluated associations of changes in statutory homelessness rates with economic activity (Gross Value Added per capita), unemployment, and local and central government expenditure.

Results Each 10% fall in economic activity was associated with an increase of 0.45 homelessness claims per 1000 households (95% CI: 0.10–0.80). Increasing rates of homelessness were also strongly linked with government reductions in welfare spending. Disaggregating types of welfare expenditure, we found that strongest associations with reduced homelessness claims were spending on social care, housing services, discretionary housing payments and income support for older persons.

Conclusions Recession and austerity measures are associated with significant increases in rates of homelessness assistance. These findings likely understate the full burden of homelessness as they only capture those who seek aid. Future research is needed to investigate what is happening to vulnerable groups who may not obtain assistance, including those with mental health problems and rough sleepers.

Objective To investigate whether the economic recession affected the control of tuberculosis in the European Union.

Methods Multivariate regression models were used to quantify the association between gross domestic product, public health expenditure and tuberculosis case detection rates, using data from 21 European Union member states (1991–2012). The estimated changes in case detection attributable to the recession were combined with mathematical models of tuberculosis transmission, to project the potential influence of the recession on tuberculosis epidemiology until 2030.

Findings Between 1991 and 2007, detection rates for sputum-smear-positive tuberculosis in the European Union were stable at approximately 85%. During the economic recession (2008–2011) detection rates declined by a mean of 5.22% (95% confidence interval, CI: 2.54–7.90) but treatment success rates showed no significant change (P=0.62). A fall in economic output of 100 United States dollars per capita was associated with a 0.22% (95% CI: 0.05–0.39) mean reduction in the tuberculosis case detection rate. An equivalent fall in spending on public health services was associated with a 2.74% (95% CI: 0.31–5.16) mean reduction in the detection rate. Mathematical models suggest that the recession and consequent austerity policies will lead to increases in tuberculosis prevalence and tuberculosis-attributable mortality that are projected to persist for over a decade.

Conclusion Across the European Union, reductions in spending on public health services appear to have reduced tuberculosis case detection and to have increased the long-term risk of a resurgence in the disease.

Greece implemented the deepest austerity package in Europe during the Great Recession (from 2008), including reductions in severance pay and redundancy notice periods. To evaluate whether these measures worsened labour market participants’ health status, we compared changes in self-reported health using two cohorts of employed individuals in Greece from the European Union Statistics on Income and Living Conditions. During the initial recession (2008–2009) we found that self-reported health worsened both for those remaining in employment and those who lost jobs. Similarly, during the austerity programme (2010–2011) people who lost jobs experienced greater health declines. Importantly, individuals who remained employed in 2011 were also 25 per cent more likely to experience a health decline than in 2009. These harms appeared concentrated in people aged 45–54 who lost jobs. Our study moves beyond existing findings by demonstrating that austerity both exacerbates the negative health consequences of job loss and worsens the health of those still employed.

This paper contributes insights into the role of tenure in modifying the relationship between housing affordability and health, using a cross-national comparison of similar post-industrial nations—Australia and the United Kingdom—with different tenure structures. The paper utilises longitudinal data from the Household, Income and Labour Dynamics in Australia Survey and British Household Panel Survey to examine change in the mental health of individuals associated with housing becoming unaffordable and considers modification by tenure. We present evidence that the role of tenure in the relationship between housing and health is context dependent and should not be unthinkingly generalised across nations. These findings suggest that the UK housing context offers a greater level of protection to tenants living in unaffordable housing when compared with Australia, and this finds expression in the mental health of the two populations. We conclude that Australian governments could improve the mental health of their economically vulnerable populations through more supportive housing policies.

Background : Is regaining a job sufficient to reverse the harmful impacts on health of job loss during the Great Recession? We tested whether unemployed persons who found work within 1 year of job loss experienced a full recovery of their health. Additionally, we tested the mediating role of financial strain and household income. Methods : Linear regression models were used to assess the effects of job loss and recovery on self-rated health using the longitudinal EU-SILC, covering individuals from 27 European countries. We constructed a baseline of employed persons ( n = 70 611) in year 2007. We evaluated income and financial strain as potential mediating factors. Results : Job loss was associated with worse self-rated health in both men (β = 0.12, 95%CI: 0.09–0.15) and women (β = 0.13, 95%CI: 0.10–0.16). Financial strain explains about one-third of the association between job loss and health, but income did not mediate this relation. Women who regained employment within 1 year after job loss were found to be similarly healthy to those who did not lose jobs. In contrast, men whose employment recovered had an enduring health disadvantage compared with those who had not lost jobs (β = 0.11, 95%CI: 0.05–0.16). Unemployment cash benefits mitigated financial strain but were too low to substantially reduce perceived financial strain among men. Conclusions : Men and women’s health appears to suffer equally from job loss but differs in recovery. For men, employment recovery was insufficient to alleviate financial strain and associated health consequences, whereas in women regaining employment leads to health recovery.

Social and economic policies are inextricably linked with population health outcomes in Europe, yet few datasets are able to fully explore and compare this relationship across European countries. The European Union Statistics on Income and Living Conditions (EU-SILC) survey aims to address this gap using microdata on income, living conditions and health. EU-SILC contains both cross-sectional and longitudinal elements, with nationally representative samples of individuals 16 years and older in 28 European Union member states as well as Iceland, Norway and Switzerland. Data collection began in 2003 in Belgium, Denmark, Ireland, Greece, Luxembourg and Austria, with subsequent expansion across Europe. By 2011, all 28 EU member states, plus three others, were included in the dataset. Although EU-SILC is administered by Eurostat, the data are output-harmonized so that countries are required to collect specified data items but are free to determine sampling strategies for data collection purposes. EU-SILC covers approximately 500,000 European residents for its cross-sectional survey annually. Whereas aggregated data from EU-SILC are publicly available [http://ec.europa.eu/eurostat/web/income-and-living-conditions/data/main-tables], microdata are only available to research organizations subject to approval by Eurostat. Please refer to [http://epp.eurostat.ec.europa.eu/portal/page/portal/microdata/eu_silc] for further information regarding microdata access.

Background How to finance progress towards universal health coverage in low-income and middle-income countries is a subject of intense debate. We investigated how alternative tax systems affect the breadth, depth, and height of health system coverage.

Methods We used cross-national longitudinal fixed effects models to assess the relationships between total and different types of tax revenue, health system coverage, and associated child and maternal health outcomes in 89 low-income and middle-income countries from 1995–2011.

Findings Tax revenue was a major statistical determinant of progress towards universal health coverage. Each US$100 per capita per year of additional tax revenues corresponded to a yearly increase in government health spending of $9·86 (95% CI 3·92–15·8), adjusted for GDP per capita. This association was strong for taxes on capital gains, profits, and income ($16·7, 9·16 to 24·3), but not for consumption taxes on goods and services (−$4·37, −12·9 to 4·11). In countries with low tax revenues (<$1000 per capita per year), an additional $100 tax revenue per year substantially increased the proportion of births with a skilled attendant present by 6·74 percentage points (95% CI 0·87–12·6) and the extent of financial coverage by 11·4 percentage points (5·51–17·2). Consumption taxes, a more regressive form of taxation that might reduce the ability of the poor to afford essential goods, were associated with increased rates of post-neonatal mortality, infant mortality, and under-5 mortality rates. We did not detect these adverse associations with taxes on capital gains, profits, and income, which tend to be more progressive.

Interpretation Increasing domestic tax revenues is integral to achieving universal health coverage, particularly in countries with low tax bases. Pro-poor taxes on profits and capital gains seem to support expanding health coverage without the adverse associations with health outcomes observed for higher consumption taxes. Progressive tax policies within a pro-poor framework might accelerate progress toward achieving major international health goals.

Background The health effects of recent economic crises differ markedly by population group. The objective of this systematic review is to examine evidence from longitudinal studies on factors influencing resilience for any health outcome or health behaviour among the general population living in countries exposed to financial crises.

Methods We systematically reviewed studies from six electronic databases (EMBASE, Global Health, MEDLINE, PsycINFO, Scopus, Web of Science) which used quantitative longitudinal study designs and included: (i) exposure to an economic crisis; (ii) changes in health outcomes/behaviours over time; (iii) statistical tests of associations of health risk and/or protective factors with health outcomes/behaviours. The quality of the selected studies was appraised using the Quality Assessment Tool for Quantitative Studies. PRISMA reporting guidelines were followed.

Results From 14,584 retrieved records, 22 studies met the eligibility criteria. These studies were conducted across 10 countries in Asia, Europe and North America over the past two decades. Ten socio-demographic factors that increased or protected against health risk were identified: gender, age, education, marital status, household size, employment/occupation, income/ financial constraints, personal beliefs, health status, area of residence, and social relations. These studies addressed physical health, mortality, suicide and suicide attempts, mental health, and health behaviours. Women’s mental health appeared more susceptible to crises than men’s. Lower income levels were associated with greater increases in cardiovascular disease, mortality and worse mental health. Employment status was associated with changes in mental health. Associations with age, marital status, and education were less consistent, although higher education was associated with healthier behaviours.

Conclusions Despite widespread rhetoric about the importance of resilience, there was a dearth of studies which operationalised resilience factors. Future conceptual and empirical research is needed to develop the epidemiology of resilience.

Unhealthy persons are more likely to lose their jobs than those who are healthy but whether this is affected by recession is unclear. We asked how healthy and unhealthy persons fared in labour markets during Europe's 2008–2010 recessions and whether national differences in employment protection helped mitigate any relative disadvantage experienced by those in poor health. Two retrospective cohorts of persons employed at baseline were constructed from the European Statistics of Income and Living Conditions in 26 EU countries. The first comprised individuals followed between 2006 and 2008, n = 46,085 (pre-recession) and the second between 2008 and 2010, n = 85,786 (during recession). We used multi-level (individual- and country-fixed effects) logistic regression models to assess the relationship (overall and disaggregated by gender) between recessions, unemployment, and health status, as well as any modifying effect of OECD employment protection indices measuring the strength of policies against dismissal and redundancy. Those with chronic illnesses and health limitations were disproportionately affected by the recession, respectively with a 1.5- and 2.5-fold greater risk of unemployment than healthy people during 2008–2010. During severe recessions (>7% fall in GDP), employment protections did not mitigate the risk of job loss (OR = 1.06, 95% CI: 0.94–1.21). However, in countries experiencing milder recessions (< 7% fall in GDP), each additional unit of employment protection reduced job loss risk (OR = 0.72, 95% CI: 0.58–0.90). Before the recession, women with severe health limitations especially benefited, with additional reductions of 22% for each unit of employment protection (AORfemale = 0.78, 95% CI: 0.62–0.97), such that at high levels the difference in the risk of job loss between healthy and unhealthy women disappeared. Employment protection policies may counteract labour market inequalities between healthy and unhealthy people, but additional programmes are likely needed to protect vulnerable groups during severe recessions.

What is the relationship between social stratification and arts participation? Because the barriers to both participation and consumption vary, the relationship between the social strata and arts participation may differ from the relationship between social strata and arts consumption. Using three pooled waves of the Taking-Part survey (N = 78,011), I estimate latent class and multinomial logistic models to examine the association between education, social status, social class, and income with patterns of arts participation. Five latent clusters are observed and both social status and social class are insignificantly associated with each cluster. In contrast, education remains strongly correlated with most forms of arts participation. These results indicate that arts participation, as a constituent part of ‘lifestyle’, is not primarily explained through social status or social class but rather through education.

Background : During the 2007–11 recessions in Europe, suicide increases were concentrated in men. Substantial differences across countries and over time remain unexplained. We investigated whether increases in unaffordable housing, household indebtedness or job loss can account for these population differences, as well as potential mitigating effects of alternative forms of social protection. Methods : Multivariate statistical models were used to evaluate changes in suicide rates in 20 EU countries from 1981–2011. Models adjusted for pre-existing time trends and country-fixed effects. Interaction terms were used to evaluate modifying effects. Results : Changes in levels of unaffordable housing had no effect on suicide rates ( P = 0.32); in contrast, male suicide increases were significantly associated with each percentage point rise in male unemployment, by 0.94% (95% CI: 0.51–1.36%), and indebtedness, by 0.54% (95% CI: 0.02–1.06%). Spending on active labour market programmes (ALMP) (−0.26%, 95% CI: −0.08 to −0.45%) and high levels of social capital (−0.048%, 95% CI: −0.0096 to −0.087) moderated the unemployment–suicide association. There was no interaction of the volume of anti-depressant prescriptions ( P = 0.51), monetary benefits to unemployed persons ( P = 0.77) or total social protection spending per capita ( P = 0.37). Active labour market programmes and social capital were estimated to have prevented ∼540 and ∼210 male suicides, respectively, arising from unemployment in the countries studied. Conclusion : Job losses were a critical determinant of variations in male suicide risks in Europe’s recessions. Greater spending on ALMP and levels of social capital appeared to mitigate suicide risks.

Background WHO stresses the need to act on the social determinants of tuberculosis. We tested whether alternative social protection programmes have affected tuberculosis case notifications, prevalence, and mortality, and case detection and treatment success rates in 21 European countries from 1995 to 2012.

Methods We obtained tuberculosis case notification data from the European Centre for Disease Prevention and Control's 2014 European Surveillance System database. We also obtained data for case detection, treatment success, prevalence, and mortality rates from WHO's 2014 tuberculosis database. We extracted data for 21 countries between Jan 1, 1995, and Dec 31, 2012. Social protection data were from EuroStat, 2014 edition. We used multivariate cross-national statistical models to quantify the association of differing types of social protection programmes with tuberculosis outcomes. All analyses were prespecified.

Findings After we controlled for economic output, public health spending, and country fixed effects, each US$100 increase in social protection spending was associated with a decrease per 100,000 population in the number of tuberculosis case notifications of −1·53% (95% CI −0·28 to −2·79; p=0·0191), estimated incidence rates of −1·70% (−0·30 to −3·11; p=0·0201), non-HIV-related tuberculosis mortality rate of −2·74% (−0·66 to −4·82; p=0·0125), and all-cause tuberculosis mortality rate of −3·08% (−0·73 to −5·43; p=0·0127). We noted no relation between increased social spending and tuberculosis prevalence (−1·50% [–3·10 to 0·10] per increase of $100; p=0·0639) or smear-positive treatment success rates (−0·079% [–0·18 to 0·34] per increase of $100; p=0·5235) or case detection (−0·59% [–1·31 to 0·14] per increase of $100; p=0·1066). Old age pension expenditure seemed to have the strongest association with reductions in tuberculosis case notification rates for those aged 65 years or older (−3·87% [–0·95 to −6·78]; p=0·0137).

Interpretation Investment in social protection programmes are likely to provide an effective complement to tuberculosis prevention and treatment programmes, especially for vulnerable groups.

Longitudinal studies of cultural engagement are uncommon. This paper explores whether there are stable latent clusters of cultural engagement over time and whether age–period–cohort (APC) effects explain within-person changes between these clusters across the life course. Using data from the British Household Panel Survey (N=25,149), I conduct longitudinal latent class analysis to uncover the latent patterns of cultural consumption across nine activities: cinema, watching live sport, attending the theatre, eating at a restaurant, doing DIY, attending an evening class, meeting with local groups, volunteering, and going to a club/pub. Then, I explore whether APC effects are observable in the data using scatterplot smoothing, lowess regression. Six latent clusters are consistently observed in each wave: None, DIY, Restaurant/Pub, Cinema/Theatre, Volunteer, and All (almost all activities). A large number of respondents have highly stable patterns of cultural engagement but there is also a substantial degree of variation. Transitions between latent clusters over time occur between those that are compositionally similar (in terms of activities). These changes in patterns of cultural engagement are partially explained by age effects, such as time constraints and health. Additionally, there is some evidence of cohort effects among the youngest cohorts moving into the “All” latent cluster, the cluster with the most cultural breadth.

Why are researchers studying the health effects of economic change reaching markedly varying conclusions? To understand these differences, we first systematically searched Web of Science for the literature on recessions and health yielding 461 articles and 14,401 cited documents. We then undertook a network analysis of co-citation pattern by disciplines, journals and backgrounds of the authors, followed by a chronological review of the literature, to trace the evolution of ideas. We then examined the extent to which earlier literature predicted what has happened in the 2007–2012 crisis. Our analysis finds the literature is dominated by disciplinary silos, with economics studies predominantly citing each other and relative isolation of psychiatry and substance abuse journals. Different philosophical approaches to assessing causality appear to contribute to varying interpretations, a tendency that is unlikely to be resolved without a shift in research norms. We conclude by calling for more inter-disciplinary research that combines empirical findings with a search for plausible mechanisms. This approach would evaluate not only the effects of economic shocks but also the mechanisms that offer protection against them.

Greece's economic crisis has deepened since it was bailed out by the international community in 2010. The country underwent the sixth consecutive year of economic contraction in 2013, with its economy shrinking by 20% between 2008 and 2012, and anaemic or no growth projected for 2014. Unemployment has more than tripled, from 7·7% in 2008 to 24·3% in 2012, and long-term unemployment reached 14·4%. We review the background to the crisis, assess how austerity measures have affected the health of the Greek population and their access to public health services, and examine the political response to the mounting evidence of a Greek public health tragedy.

There has been a substantial rise in ‘economic suicides' in the Great Recessions afflicting Europe and North America. We estimate that the Great Recession is associated with at least 10 000 additional economic suicides between 2008 and 2010. A critical question for policy and psychiatric practice is whether these suicide rises are inevitable. Marked cross-national variations in suicides in the recession offer one clue that they are potentially avoidable. Job loss, debt and foreclosure increase risks of suicidal thinking. A range of interventions, from upstream return-to-work programmes through to antidepressant prescriptions may help mitigate suicide risk during economic downturn.

Why have patterns of healthcare spending varied during the Great Recession? Using cross-national, harmonised data for 27 EU countries from 1995 to 2011, we evaluated political, economic, and health system determinants of recent changes to healthcare expenditure. Data from EuroStat, the IMF, and World Bank (2013 editions) were evaluated using multivariate random- and fixed-effects models, correcting for pre-existing time-trends. Reductions in government health expenditure were not significantly associated with magnitude of economic recessions (annual change in GDP, p = 0.31, or cumulative decline, p = 0.40 or debt crises (measured by public debt as a percentage of GDP, p = 0.38 or per capita, p = 0.83)). Nor did ideology of governing parties have an effect. In contrast, each $100 reduction in tax revenue was associated with a $2.72 drop in health spending (95% CI: $1.03–4.41). IMF borrowers were significantly more likely to reduce healthcare budgets than non-IMF borrowers (OR = 3.88, 95% CI: 1.95 –7.74), even after correcting for potential confounding by indication. Exposure to lending from international financial institutions, tax revenue falls, and decisions to implement cuts correlate more closely than underlying economic conditions or orientation of political parties with healthcare expenditure change in EU member states.

Background Is existing provision of health services in Europe affordable during the recession or could cuts damage economic growth? This debate centres on whether government spending has positive or negative effects on economic growth. In this study, we evaluate the economic effects of alternative types of government spending by estimating “fiscal multipliers” (the return on investment for each $1 dollar of government spending).

Methods Using cross-national fixed effects models covering 25 EU countries from 1995 to 2010, we quantified fiscal multipliers both before and during the recession that began in 2008.

Results We found that the multiplier for total government spending was 1.61 (95% CI: 1.37 to 1.86), but there was marked heterogeneity across types of spending. The fiscal multipliers ranged from −9.8 for defence (95% CI: -16.7 to −3.0) to 4.3 for health (95% CI: 2.5 to 6.1). These differences appear to be explained by varying degrees of absorption of government spending into the domestic economy. Defence was linked to significantly greater trade deficits (β = −7.58, p=0.017), whereas health and education had no effect on trade deficits (peducation=0.62; phealth= 0.33).

Conclusion Our findings indicate that government spending on health may have short-term effects that make recovery more likely.

STOA, the European Parliament's technology assessment body, and the European Observatory on Health Systems and Policies recently organised a workshop on the impacts of the economic crisis on European health systems. Evidence of the impact of the recent financial crisis on health outcomes is only just beginning to emerge. Data suggests that this latest recession has led to more frequent poor health status, rising incidence of some communicable diseases, and higher suicide rates. Further, available data are likely to underestimate the broader mental health crisis linked to increased rates of stress, anxiety, and depression among the economically vulnerable. Not only does recession affect factors that determine health, but it also affects the financial capacity to respond. Many European governments have reduced public expenditure on health services during the financial crisis, while introducing or increasing user charges. The recession has driven structural reforms, and has affected the priority given to public policies that could be used to help protect population health. The current economic climate, while challenging, presents an opportunity for reforming and restructuring health promotion actions and taking a long-term perspective.

Correlations between social class and sport participation have frequently been observed (Crook 1997; Ceron-Anaya 2010; Dollman and Lewis 2010; Stalsberg and Pedersen 2010). However, discrete associations between occupational class positions and specific sporting activities overlook the complex interrelationships amongst these sports. Until recently understanding the relationality of sport has been constrained by a lack of available and appropriate data. Work by Bourdieu (1984), and more recently Bennett et al. (2009), have explored the general field of cultural consumption and sport has been one dimension of these treatments. Using multiple correspondence analysis (Le Roux and Rouanet 2004), this research focuses upon the social space of sport participation in Britain in order to provide a more detailed account of how these activities are organised. From data in the Taking-Part Survey (n = 10,349), which was gathered between July 2005-October 2006, 19 sporting practices are situated along four key dimensions. The first dimension separates gender and corresponds to a division between an embodied or social focus. Dimension two captures the impact of age. Internal and external orientations divide dimension three, where men tend to be internally oriented. Class, education and social status are significant along this dimension. Dimension four differentiates self-employed and manual workers; reinforcing occupational and educational differences. Consequently, the social space of sports participation cannot be neatly contained within the logic of class; other explanations drawing on friendship, education and embodiment are also required.