Health Inequalities and Policy Research (HIPR) Group: Summary of research findings

February 24th, 2025 by Davara Bennett

Adult mental health and wellbeing

Journal article, 2023. Inequalities in local government spending on cultural, environmental and planning services: a time-trend analysis in England, Scotland, and Wales.

https://doi.org/10.1186/s12889-023-15179-9

Local government provides Cultural, Environmental, and Planning (CEP) services, such as parks, libraries, and waste collection, that are vital for promoting health and wellbeing. In this study, we assessed trends in the funding of CEP services between 2009 and 2018 in Great Britain. We found that:

Spending on CEP services reduced by 36% between 2009 and 2018.

In England, budget cuts were steepest in more deprived areas, compared to more affluent areas. Spending reduced by 7.5% each year in the most deprived areas, compared to 4.5% each year in the least deprived areas.

Budget cuts in Scotland and Wales were more equitable, with similar trends observed in both deprived and affluent areas.

The share of local government budgets spent on CEP services declined over the period. This suggests CEP services are becoming less of a local priority as budgets become constrained.

The inequalities in CEP budget cuts may exacerbate geographical inequalities in health and wellbeing.

Journal article, 2023. Mental health impact of cuts to local government spending on cultural, environmental and planning services in England: a longitudinal ecological study.

https://doi.org/10.1186/s12889-023-16340-0

Between 2011 and 2019, local government spending on cultural, environmental and planning services fell by 17%, with deeper cuts in more deprived areas. These services include parks, leisure centres, community development, libraries, waste collection, and other similar functions. In this study, we evaluated the mental health impacts of these budget cuts, adjusting for confounding factors. Our findings revealed that:

The cuts to cultural, environmental and planning services were associated with small negative mental health impacts, such as increased antidepressant prescriptions and self-reported anxiety.

The mental health impacts were mainly caused by cuts to planning services, which include community and economic development in addition to traditional planning activities.

Effect sizes were larger in affluent areas compared to deprived areas. This could reflect geographic patterning in quality of services and barriers to access.

Reinvesting in these services, especially planning, could lead to improvements in public mental health.

Project report, 2024. Evaluating the health impact and cost-effectiveness of Citizens Advice on Prescription, a whole system approach to mitigate poverty over the life course.

https://fundingawards.nihr.ac.uk/award/NIHR202465

This project investigated whether Citizens Advice on Prescription – a scheme that provides people using health services in Liverpool with advice and support to improve their financial and living conditions – improved people’s mental health and wellbeing. We interviewed people using the service, and people involved in providing the service, to understand what worked well and what did not.

We found consistent evidence, using different methods, that Citizens Advice on Prescription improved mental health and wellbeing.

This included improvements in self-reported health, wellbeing, anxiety and depression following the intervention.

Our estimates show that the intervention caused a reduction in antidepressant prescribing, GP consultations and A&E attendances

Qualitative accounts described how the intervention led to these effects.

Overall, we estimate that the intervention saved the NHS money.

The characteristics of the service that seemed to be important for effectiveness were:

A simple and accessible referral approach

Directly contacting clients

A trusting relationship providing expert advice and emotional support

The opportunity to re-engage with the service if needed

Health care professionals who were confident talking with patients about their financial circumstances.

Project report, 2024. The health and health inequalities impact of a place-based community wealth initiative, a mixed methods study.

https://fundingawards.nihr.ac.uk/award/NIHR130808

Community Wealth Building in Preston aimed to boost the economy for more disadvantaged groups, by encouraging public sector and large charitable organizations to buy more services from local suppliers, help develop new charities and cooperatives, and improve wages. We evaluated whether, by improving wages and reducing employment, this initiative led to improvements in health. We found that:

Community Wealth Building in Preston led to a reduction in mental health problems, improved wellbeing, wages, employment, and the establishment of new charities in Preston, compared to other areas with similar characteristics.

These improvements tended to be greatest in more disadvantaged groups.

Preston City Council was more likely to buy services from local suppliers compared to other similar local authorities and this practice is likely to have contributed to economic benefits.

There was no evidence that procuring locally increased costs.

People we interviewed highlighted that the programme had initially focused on changes in how institutions spent their money. Involvement of the public and community groups had been more limited.

Community Wealth Building offers an effective strategy for promoting inclusive economic growth that improves mental health and wellbeing and reduces inequalities. Future development should aim for greater civic engagement.

Journal article, 2024. Ambient greenness, access to local green spaces, and subsequent mental health: a 10-year longitudinal dynamic panel study of 2·3 million adults in Wales.

https://doi.org/10.1016/S2542-5196(23)00212-7

In this study, we analysed data on more than 2 million people in Wales over 10 years to explore the impact of green spaces on mental health. We linked information about people’s mental health with information about the greenness of their home’s immediate surroundings and how close they lived to green or blue spaces (such as parks, lakes, and beaches). We found that greenness reduced the risk of anxiety and depression. In particular:

The highest level of greenness of home surroundings was associated with 20% less anxiety and depression than the middle level; the middle level with 20% less than the lowest level.

Every 10% increase in access to green and blue spaces was linked with a 7% reduction in risk of anxiety and depression

People in poorer areas benefitted more (10% reduced risk of anxiety and depression) from access to green and blue spaces than those in richer areas (6% reduced risk)

People with a previous diagnosis (anxiety and depression before 2008) benefitted more than others from green home surroundings, but not from greater access to green spaces.

We conclude that local authorities could improve the mental health of their community by increasing the greenery in their towns and cities and improving access to green and blue spaces.

Child health outcomes

Journal article, 2022. Mediators of socioeconomic inequalities in preterm birth: a systematic review.

https://doi.org/10.1186/s12889-022-13438-9

This review aimed to identify mediators of the relationship between maternal socioeconomic status and preterm birth: the risk factors which are affected by maternal socioeconomic conditions and in turn affect preterm birth rates. It also aimed to assess the strength and quality of the evidence.

There was high confidence that smoking during pregnancy, the most frequently examined mediator, and maternal physical health, mediated inequalities in preterm birth.

But significant residual inequalities frequently remained. The substantial socioeconomic inequalities in preterm birth are only partly explained by the six groups of mediators that have been studied.

Despite the limitations of our methods, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is necessary to address inequalities in preterm birth, alongside action on mediating pathways.

Journal article, 2024. Intersecting ethnic and socioeconomic inequalities in infant mortality in England, 2007–2019.

https://doi.org/10.1136/archdischild-2023-326619

Researchers from the Children and Young People and Families theme of the School for Public Health Research investigated patterns of infant mortality in England using openly available national data. Infant mortality, or babies dying before their first birthday, is a serious problem in the UK. It is much more common in poorer communities and among certain ethnic groups. The researchers looked at infant mortality rates across different area levels of poverty and different ethnic backgrounds in England from 2007 to 2019. They found that:

Infant mortality was higher in the most deprived areas compared to the wealthiest areas. This pattern was seen for most ethnic groups.

However, for Black infants, the mortality rate was very high regardless of how wealthy or poor their family was. The rate was nearly double the national average, even for Black infants born into well-off families.

This suggests that factors beyond just poverty, like racism and discrimination, are contributing to the high infant mortality rates in the Black community. The researchers say more detailed studies are needed to fully understand these complex inequalities.

Overall, the findings highlight the urgent need to address the unacceptable gaps in infant mortality, especially for Black babies. Tailored, equity-focused efforts are required to ensure all infants, regardless of their background, have the best chance at a healthy start to life.

Journal article, 2024. Implications of child poverty reduction targets for public health and health inequalities in England: a modelling study between 2024 and 2033.

https://doi.org/10.1136/jech-2024-222313

This study was led by colleagues in Glasgow. They used estimates of the impact of child poverty on a range of child health outcomes – including care entry, using estimates from a prior HIPR study – to model what would happen under different poverty reduction scenarios between 2024 and 2033. They found that:

All poverty reduction scenarios would improve child health.

Meeting the high ambition scenario of a 35% reduction in child poverty would lead to an estimated 293 fewer cases of infant mortality (95% CI 118 to 461), 4696 fewer children entering care (95% CI 1987 to 7593), 458 fewer cases of nutritional anaemia (458, 95% CI 336 to 574) and 32,650 fewer emergency admissions (95% CI 4022 to 61 126).

Northern regions and more deprived places would see the greatest benefit.

Journal article, 2024. Effect of Universal Credit on young children’s mental health: quasi-experimental evidence from Understanding Society.

https://doi.org/10.1136/jech-2024-222293

This study aimed to determine whether the introduction of Universal Credit was associated with increased mental health issues among young children (aged 5 or 8 years) of parents who were unemployed and eligible for Universal Credit. It also explored potential explanations for a rise in mental health issues in young children – for example more time spent in childcare instead of with parents, or changes in household income. Using data from the Understanding Society longitudinal Survey between 2012 and 2018, we found:

That the prevalence of mental health problems among eligible children whose parents were unemployed increased, with an odds ratio of 2.18 (95% CI 1.14 to 4.18), corresponding to an 8-percentage point rise (95% CI 1 to 14) following the introduction of Universal Credit in 2016.

That the prevalence of socioemotional behavioural difficulties increased significantly for eligible children in families with two or more children and for children aged 8, while no significant effects were observed for their counterparts.

No evidence that utilisation of childcare services or changes in household income explained the impact of Universal Credit on children’s mental health.

These findings suggest that the introduction of Universal Credit had effects that extended to recipients’ children, underscoring the broader implications of welfare reforms for family well-being.

Journal article, 2024. How are socioeconomic inequalities in preterm birth explained by maternal smoking and maternal body mass index: A mediation analysis.

https://doi.org/10.1111/ppe.13045

Using a bespoke extract of data from Liverpool Women’s Hospital between 2009 and 2020, we estimated how much of the association between socioeconomic status and gestational age at birth is explained by maternal smoking status and maternal body mass index. We found that:

The proportion of inequalities explained by smoking alone was 33.9% for extremely preterm births (<28 weeks), 43.0% for very preterm births (28-32 weeks) and 48.4% for moderately preterm births (32-27 weeks).

Inequalities were not explained by maternal body mass index.

Using novel mediation methods, this analysis adds robust evidence for the explanation of inequalities in preterm birth.

Children experiencing social care intervention

Journal article, 2020: Trends in inequalities in Children Looked After in England between 2004 and 2019: a local area ecological analysis.

https://doi.org/10.1136/bmjopen-2020-041774

This study assessed trends in inequalities in children entering care in England between 2004 and 2019, after controlling for unemployment, a marker of the recession:

From 2007, there was a steep rise in care entry rates in England, greater in more income-deprived local authorities.

Socioeconomic inequalities increased independently of the effect of unemployment. Between 2007 and 2019, after controlling for unemployment, the gap between most and least deprived areas increased by 15 children per 100,000 per year (95% CI 4-26) relative to the 2004-2007 trend.

The risk of being taken into care in England has become increasingly clustered in poor places. Yet the funding formula for distributing central government funds to local authority Children’s Services, based on 2001 data, was last revised in 2013-14. One key policy implication of this study is that this funding formula is no longer fit for purpose; it needs urgent updating to ensure appropriate resource allocation going forward.

Journal article, 2021. Funding for preventative children’s services and rates of children becoming looked after: a natural experiment using longitudinal area-level data in England.

https://doi.org/10.1016/j.childyouth.2021.106289

Between 2011 and 2019, as rates of children in care increased, local authority spending on preventative services for children and families fell by about 25% in real terms, with deeper cuts in more deprived areas. In this study, we assessed the impact of prevention spend on rates of preschool children and adolescents entering care the following year, controlling for confounders:

There was no evidence of an association between prevention spend and care entry for pre-school children.

However, there was an association for adolescents. Every £10 per child decrease in adolescent spend was associated with an estimated additional 1.9 per 100,000 children aged 16-17 entering care the following year (95% CI 0.7 to 2.9).

This is equivalent to 1 in 25 care entries in this age group over the study period.

We conservatively estimate that cuts to prevention services for adolescents totally £58 million incurred an additional £60 million in short-run placement costs – conservative, because these older children often have some of the most complex needs, and require costly specialist support and residential placements.

These findings highlight the importance of equitable reinvestment in prevention. Specifically, they point to the protective impact of adolescent services, which may yield relatively short-term benefits, reducing steep care costs that might otherwise have been incurred.

Journal article, 2022. Child poverty and children entering care: a longitudinal ecological study at local area-level in England, 2015-2020.

https://doi.org/10.1016/s2468-2667(22)00065-2

The stark rise in care entry has coincided with rising child poverty, a risk factor for children entering care. Our aim this study was to assess the contribution of recent trends in child poverty to trends in care entry:

Between 2015 and 2020 and controlling for employment rates, a 1 percentage point increase in child poverty was associated with 5 additional children entering care per 100,000 [95% CI 2–8].

We estimate that, over the study period, 8.1% [95% CI 5·0%–11·3%] of care entries were linked to rising child poverty, equivalent to 10,351 [95% CI 6,447–14,567] additional children taken into care in England over this period.

The additional placement costs alone are estimated at £1.4 billion. To put that in context, it would cost £0.25 billion per year to support 250,000 children out of deep poverty by abolishing the benefit cap. It would cost £1.3 billion per year to lift a further 250,000 children out of poverty by abolishing the two-child limit.

Children’s exposure to poverty creates and compounds adversity, driving poor health and social outcomes in later life. National anti-poverty policies are key to tackling adverse trends in care entry in England.

Journal article, 2022. Monitoring a fragile child protection system: a longitudinal local area ecological analysis of the inequalities impact of children’s services inspections on statutory child welfare interventions in England.

https://doi.org/10.1017/S0047279422000587

A recurring theme in prior qualitative research is local authority policymakers’ preoccupation with the growing power of Ofsted. In one HIPR research project, several study participants asserted that poor inspection judgements led to a spike in care entry; one suggested that this would inevitably increase inequalities. In this study, we evaluated these claims empirically:

Between 2010 and 2020, Ofsted inspection was associated with a rise in rates across the spectrum of social care interventions. Worse judgements yielded higher rates. Relative to local authorities that received no inspection, those judged to require improvement saw a 3.2% increase in care entry rates (95% CI 0.8%, 5.7%). For those judged inadequate, this rose to 4.6% (95% CI 0.9%, 8.5%).

Inadequate Ofsted judgements were reliably met with a spike in more acute care and child protection plan interventions across all local authorities, regardless of deprivation levels. However, in more deprived local authorities, this was at the expense of more supportive child-in-need interventions.

We conclude that, while Ofsted may not be a main driver of inequalities, it likely reflects and exacerbates underlying socioeconomic inequalities. We go on to demonstrate this in a companion study.

Ultimately, a child and family’s experience of the child protection system may be very different depending on where a local authority finds itself in a cycle of inspection.

To sustainably improve service quality, Ofsted must grapple with the unintended consequences of inspection, and acknowledge the wider socioeconomic determinants of service quality.

Journal article, 2022. Austerity, Poverty, and Children’s Services Quality in England: Consequences for Child Welfare and Public Services.

https://eprints.whiterose.ac.uk/181694/

This study, led by Dr Calum Webb, forms a companion piece to a study of the impact of Ofsted inspection on care entry. It aimed to assess the association of local socioeconomic conditions – both local authority deprivation and prevention spend – with Children’s Service quality, as judged by Ofsted:

Each £100 increase in preventative spending per child was associated with a 69% increase (95%CI: 27.5,124) in the odds of a positive inspection.

A one-decile increase in deprivation was associated with a 16% (95% CI: −25%, −5.7%) decrease.

In short, deprived communities have worse access to good-quality children’s services. Government policies that have increased poverty and retrenched preventative services have likely exacerbated this inequality.

The findings roundly challenged the dominant policy narrative in England at the time, which recognised no association between spending on children’s services and quality, and only a limited association between quality and deprivation.

Journal article, 2023. Impact of socio-economic conditions and perinatal factors on risk of becoming a child looked after: a whole population cohort study using routinely collected data in Wales.

https://doi.org/10.1016/j.puhe.2023.09.001

In this study, led by colleagues within the Health Inequalities Policy Research group and Secure Anonymised Information Linkage databank, we aimed to assess how deprivation and maternal and child perinatal characteristics inﬂuenced the risk of entering care in Wales. We used a whole population cohort to demonstrate that:

In Wales, children from the most deprived quintile are 3.4 times more likely to enter care than those in the least deprived (3.40, 95% CI 3.08, 3.74).

Maternal mental health problems in pregnancy are associated with higher risk of becoming looked after (2.03, 95% CI 1.88–2.19).

We estimate that if children in the most deprived ﬁfth had the same level of deprivation as those in the least deprived ﬁfth, care rates would fall by 22% (95% CI 0.20, 0.24).

Successfully tackling maternal mental health issues might reduce the risk of children entering care by as much as 20%.

Journal article, 2024. Poverty and children entering care in England: a qualitative study of local authority policymakers’ perspectives of challenges in Children’s Services

https://doi.org/10.1016/j.childyouth.2024.107689

Poverty is a causal factor in child maltreatment. In prior studies, we exposed the major contribution of rising child poverty to trends in care entry, and stressed the need for anti-poverty policies. But to make their mark on Children’s Services, policy recommendations must be attuned to the local decision-making context. In this study, we interviewed Children’s Services policymakers. We aimed to assess the status of poverty on the policy agenda:

The scale and urgency of the problem of rising care entry was evident across interviews.

Participants raised the problem of poverty in relation to care entry, but hesitantly, tentatively, and never in plain causal terms. This is a major obstacle to implementing anti-poverty policies: a problem that cannot be readily named, does not reach the policy agenda.

For some, the concept of ‘stress’ was key to explaining the troubling connection between poverty and out-of-home care.

But many participants also exhibited ‘causal aversion’ when explaining the relationship, conspicuously avoiding causal language. Hesitation, clarification, and caveat betrayed a general anxiety about stigmatising poverty and flattening complexity.

Participants appeared more comfortable describing the harmful impact of clusters of more proximal, behavioural risk factors. Amid these clusters, causal chains were flattened, and the significance of poverty minimised.

This contrasts with the prominent place of deprivation in participants’ between-local authority comparisons. However, in these confident comparisons, deprivation was more of an explanation than a target for intervention.

Few participants proposed concrete policies to address adverse socioeconomic circumstances – but some did, imagining solutions that attended to families’ material realities. Some cited the work of specific child welfare inequalities researchers. These researchers’ ideas may slowly be gaining traction at a local level. They should continue to press their proposed solutions in the local policy arena.

Journal article, 2024. Socioeconomic and psychosocial outcomes of parents with children in out-of-home care: A scoping review.

https://doi.org/10.1016/j.childyouth.2024.107854

This review, led by colleagues in Sweden, brings together all the quantitative evidence on the socioeconomic and psychosocial outcomes of parents who have had a child taken into care. We found that:

Overall, the evidence was sparse, and of low methodological quality. Only 15 relevant studies were identified from across OECD countries, and none from the UK.

The studies largely focused on mothers.

Most showed that having a child placed taken into out-of-home care is associated with a deterioration of parents’ socioeconomic and psychosocial outcomes.

Out-of-home care is a drastic state intervention. It marks a crisis accompanied by painful and intense emotions. Parents – often mothers – deserve tailored support to address their material and psychosocial needs, and move towards their family goals.

Journal Article, 2024. What factors are associated with children being taken into care by the state after initial contact with services? A survival analysis of Children’s Social Care data in Liverpool.

https://doi.org/10.1136/bmjph-2024-001130

This study aimed to identify predictors of children being taken into care by the state once children referred to, and assessed by, Liverpool City Council Children’s Services. We identified the key factors that increased the risk of a child becoming looked after. These were:

Neglect, sexual abuse, emotional abuse

Drug and/or alcohol use in the household or the child

Mental ill health in the household.

Children who had a Child in Need intervention were less likely to become looked after.

Children who had a Child Protection Plan were more likely to become looked after.

Children who were referred to social care at younger ages were more likely to become looked after

Black and Asian children were more likely than White children to become looked after.

Our findings highlight potential areas for service change and can be used to inform risk prediction and preventative action, however, the local context may influence how relevant our findings are to other settings.

Employment

Journal article, 2020. What is the effect of changing eligibility criteria for disability benefits on employment? A systematic review and meta-analysis of evidence from OECD countries.

https://doi.org/10.1371/journal.pone.0242976

Many countries have introduced restrictions in the eligibility requirements for disability benefits, on the assumption that these will increase work incentives for people with chronic illness and disabilities. Evidence to support this assumption is unclear, but there is a danger that removal of social protection without increased employment would increase the risk of poverty among disabled people. We therefore systematically reviewed the evidence on the employment effects of changes to eligibility criteria across OECD countries. We found:

No firm evidence that changes in eligibility affected employment of disabled people.

Restricting eligibility therefore has the potential to lead to a growing number of people out of employment with health problems who are not eligible for adequate social protection, increasing their risk of poverty.

Policymakers and researchers need to address the lack of robust evidence for assessing the employment impact of these types of welfare reforms as well as the potential wider poverty impacts.

Gastrointestinal infections

Protocol, 2024. Understanding the impact of funding cuts on Environmental and regulatory services and gastrointestinal infections: a longitudinal ecological study

https://doi.org/10.3310/nihropenres.13426.2

Local government services play an important role in protecting public health, particularly through Environmental and Regulatory Services. These services ensure that food establishments are clean and safe, reducing the spread of stomach bugs that cause diarrhoea and vomiting. However, since the 2008 financial crisis, funding for these services has been significantly reduced. The impact of these cuts on services and health outcomes remains unclear. This protocol outlines a study in which we will:

Describe trends in local government funding cuts to Environmental and Regulatory Services, and any inequalities in these trends

Understand how these local funding cuts are affecting service provision including the number of staff, food safety inspections, and hygiene ratings

Investigate whether changes in funding and service provision are linked to stomach bug rates, including hospitalisations, calls to health services, and lab-reported cases. In addition, we will explore any inequalities in these outcomes.