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Table 3 Summary of results

From: How do macro-level structural determinants affect inequalities in mental health? – a systematic review of the literature

Article Aim Study population (sample size); Study design; Country Policy sub-area MH aspect
Type of inequality assessed
Change in inequality
Policy domain – Welfare States
Artazcoz L, Cortès I, et al. 2013. [21] +++ Analyse the relationship between health status, paid working hours and household composition across family policy typologies. 25–64 years (only those employed and partnered)
27 European countriesb
Family policy Mental well-being (WHO-5) Focus: Gender inequalities (Korpi’s welfare regime typology)
Dual-earner/dual-carer models had better mental health outcomes for both sexes than other family policy models.
De Moortel D, Palència L, et al. 2015. [22]
Investigate across welfare regimes, the association between neo-Marxian social class (NMSC) and employee mental well-being and identify any gender differences. 15–65 years
21 European countriesb
Employment, social insurance and gender policies Mental well-being
Focus: Gender and SES inequalities (NMCS) (Korpi’s welfare regime typology)
Across all welfare regimes, men reported better mental well-being than women and this difference is stronger in lower SES.
Inequalities in mental well-being related to SES was found in Contradictory, State corporatist/family support and Southern welfare regimes but not in Basic security-market oriented welfare regime. No SES differences in mental well-being among women in dual earner models but differences in men.
De Moortel D, Vandenheede H, et al. 2014. [23]
Assess whether measures of employment quality are related to mental well-being and if this relationship differs by gender and across different welfare models. 15–65 years employed
21 European countriesb
Employment conditions Mental well-being (WHO-5) Focus: Gender inequalities (Korpi’s welfare regime typology)
Gender differences in mental well-being are least pronounced in earner-carer countries.
Niedzwiedz CL, Mitchell RJ, et al. 2016. [24]
Investigate whether spending on 3 types of social protection (unemployment, ALMPs, family) influences social inequality in depressive symptoms. 20–64 years
18 European countriesb
Unemployment, ALMPs, family policy Depression
Focus: SES inequalities
Decrease in benefit levels or increased conditionality may decrease mental health of disadvantaged groups.
Increase in social protection may reduce inequalities in depressive symptoms.
Nordenmark M, Strandh M, et al. 2006. [25]
Investigate the impact of unemployment benefit system for mental well-being in different welfare regimes. Unemployed persons
(N = 3442)
Longitudinal (cohort)
Britain, Ireland and Sweden
Unemployment benefits Mental distress (GHQ-12) Focus: SES inequalities (Esping-Andersen’s weflare typology)
Welfare regime has significant impact on mental well-being of the unemployed. Inverse class gradient in mental well-being in Ireland and UK compared to a positive class gradient in mental well-being in Sweden.
Flat-rate benefits decrease the mental health of those with higher SES. Income replacement benefits tend to maintain pre-unemployment differences in mental distress.
Sekine M, Chandola T, et al. 2009. [26]
Investigate socio-economic differences in work characteristics and health in Finland, Japan and the UK. 40–60 years (civil servants)
Longitudinal (cohort)
Finland, UK, Japan
Employment conditions and work characteristics Mental health functioning (SF-36) Focus: SES inequalities
Japanese males, lower SES tended to have poorer mental health functioning.
No consistent SES differences in mental health functioning were observed among British and Japanese women.
Finnish men and women, higher SES had poor mental health functioning.
Sekine M, Tatsuse T, et al. 2011. [27]
Investigate whether work characteristics contribute to sex inequalities in health in liberal, social democratic and conservative welfare states. 40–60 years (civil servants)
Longitudinal (cohort)
Finland, UK, Japan
Employment conditions and work characteristics Mental health functioning (SF-36) Focus: Gender inequalities
Poor mental health functioning was largest among Japanese women, followed by British women, then Finnish women.
Sex differences in mental health functioning were the smallest in the Finnish population.
Van de Velde S, Bambra C, et al. 2014. [28]a
Examine whether there are smaller inequalities between lone and cohabitating mothers in welfare regimes with higher levels of universalism and policies targeted at defamilising. Women 18–55 years w/ children aged 18 years or younger (N=26,499)a
27 European countriesb
Unemployment, family policy Depression (CES-D 8) Focus: Gender inequalities (Ferrera’s welfare typology) and SES
Larger mental health differences between lone and cohabitating mothers in Britain than in Sweden.
Welfare regime seems to moderate inequalities in mental health between lone and cohabitating mothers. Lowest inequalities found in Nordic welfare regimes and largest in Bismarckian regimes.
Relationship between measures of SES and mental health among lone mothers according to welfare state less clear, but Bismarckian and Nordic models were more equal according to education level.
Yur’yev A, Värnik A, et al. 2012. [29] ++ Assess the relationship between suicide mortality and social expenditure. European countries; (N= 26)
Time trends, Ecological
26 European countriesb
Social expenditure Suicide (S) Focus: No explicit inequality focus but analysis is stratified by sex
Increased social expenditure associated with decrease in female suicides in most countries.
Sub-domain: Family policy
Chandola T, Martikainen P, et al. 2004. [30]
Examine whether welfare states with more family friendly workplace policies mitigates the effect of work and family conflict on mental health and whether there are differences between men and women. Employed aged 35–60 years
Finland, Japan, UK
Family-friendly workplace policies Mental health functioning (SF-36 MCS) Focus: Gender inequalities
Single fathers in all 3 countries, single mothers in Finland had poorer mental health compared to other family arrangements. But Finnish men and women had better mental health and less conflict between work and family than the other countries.
Welfare states with more family-friendly workplace policies may reduce inequalities in mental health for women, except for single parents.
Hewitt B, Strazdins L, et al. 2017. [31]
Investigate the health effects of the introduction of a new universal paid parental leave (PPL) scheme in Australia. Employed mothers (N=5615) (2347 pre-PPL, 3268 post-PPL)
Cross-sectional, longitudinal
Paid parental leave Mental well-being (SF-12) Focus: SES inequalities
The Scheme improved mental health of all mothers but did not reduce gap in SES inequalities among mothers.
Huang J, Kim Y, et al. 2017. [32]
Examine whether an economic intervention that encourages families to accumulate assets, reduces the social-emotional inequalities between children of unmarried mothers versus married mothers. Mothers 18 years plus
Natural policy experiment - Longitudinal
Child Development Accounts (CDA) Emotional development
Focus: SES (single mothers as a proxy for low SES)
CDA have positive effects on social-emotional development for children living with unmarried mothers.
Intervention could reduce mental health inequalities between children of unmarried and married mothers.
Rathmann K, Pförtner T-K, et al. 2016. [33]
Examine whether increased public spending relates to lower prevalence of mental health complaints and buffers against inequalities among adolescents. Adolescents aged 11, 13 and 15-year-olds
27 European countriesb
Family benefits Psychological health complaints (HSBC symptom checklist) Focus: SES (Family Affluent Scale)
Social protection, especially family benefits, is positively linked to better overall mental health among young people.
Increase in family benefits widened social inequalities during economic recession.
Sub-domain: Employment
Andersen I, Brønnum-Hansen H, et al. 2016 [34] +++c Study the impact of ALMP and stricter eligibility criteria for income support among people with chronic illness, on their employment rate and receipt of non-health related benefits. Residents aged 20–60 years
Register-based cohort, cross-sectional
ALMPs and income support Psychiatric diagnosis (Hospital records and anti-depressant, anxiolytic & neuroleptic prescriptions) Focus: Gender and SES inequalities
Increase in mental health problems for those in lower SES group after austerity measures in Denmark.
No gender disparities reported.
Sub-domain: Income support / social insurance
Barr B, Kinderman P, et al. 2015. [35] +++c Investigate whether mental health trends increased during a period of recession and welfare reform and whether inequalities existed in these trends. 18–59 years (N =2,171,741)
Longitudinal (time trends)
Disability, unemployment & housing benefits Self-reported poor mental health Focus: SES (unemployment and low education as a proxy for low SES)
Increase in mental health problems were greatest amongst people outside of work and with low education.
Increased inequalities following austerity measures and welfare reforms.
Barr B, Taylor-Robinson D, et al. 2016. [36]
Investigate whether the new UK disability assessment was associated with an increase in poor mental health and whether these changes differed between local authorities. 18–64 years (N = 149 local authorities)
Longitudinal (natural policy experiment)
Disability benefits reassessments Suicide, anti-depressant prescriptions and self-rated mental health (S) Focus: SES inequalities (local area inequalities)
Increase in mental health problems associated with change in policy.
Greatest increase in mental health problems especially for persons living in most deprived areas.
Policy increased health inequalities between different deprived and non-deprived areas.
Blomqvist S, Burström B, et al. 2014. [37]
Investigate whether health inequalities increased between employed and unemployed women between 2010 compared to 2006 after major Swedish social insurance reforms. 18–64 years (N= 24,258)
(2006–13,630; 2010–10,268)
Repeated cross-sectional
Social insurance incl. Sickness + unemployment insurance Mental distress (GHQ12) Focus: SES inequalities (employed vs. unemployed)
Mental distress increased in all groups but more so among groups outside the labour market (i.e. lower SES group).
Van der Wel KA, Bambra C, et al. 2015. [38] +++ Investigate whether the association between poor working conditions or a low level of education and poor mental health is less in countries providing higher levels of sickness benefit provisions. 25–60 years (working individuals)
28 European countriesb
Sickness benefits and working conditions Mental well-being (WHO-5) Focus: SES inequalities (low education, exposure to psychosocial strain and physically hazardous work)
mental well-being was better for those who were exposed to psychosocial job strain and physical hazards or low education in countries with more generous sickness benefit provision.
Mental health inequalities were smaller in countries with more generous sickness benefits
Policy domain – Area-based initiatives
Mohan G, Longo A, et al. 2017. [39] +++ Assess the health impacts of a major urban regeneration policy. Household members aged 16 years and older
(N = 3458, Wave 1; N=1550, Wave 2)
Longitudinal (Quasi-experimental design)
Northern Ireland
Neighbourhood renewal Mental distress (GHQ-12) Focus: Gender and SES
No discernable impact on mental distress or health inequalities.
Stafford M, Badland H, et al. 2014 [40]
Determine whether the New Deal for Communities (NDC) intervention contributed towards reducing health inequalities and their social determinants Men 25–65 yearsWomen 25–60 years
(N = 109,207)
Area-based intervention - New Deal for Communities (NDC) Mental health and mental distress
(MHI-5 and GHQ-12)
Focus: SES inequalities
No discernable impact on poor mental health between NDC areas and non-NDC areas.
Walthery P, Stafford M, et al. 2015 [41]
Determine whether the NDC program had an overall effect on mental health over time and whether these changes differ between socio-economic groups. 16 years and older
(N = 11,648)
Longitudinal (Cohort)
Area-based intervention - NDC Mental health
Focus: SES inequalities
No overall effect of NDC but some evidence that mental health improved for women.
Increase in inequality in mental health between low and high socio-economic groups in control group.
  1. +++ High quality study; ++ Medium quality study
  2. ALMP Active Labour Market Policies
  3. ASQ-SE Ages and Stages Questionnaire
  4. CDA Child Development Accounts
  5. CES-D8 Center for Epidemiological Studies Depression Scale
  6. GHQ-12 Global Health Questionnaire
  7. HSBC Health Behavior in School Age Children
  8. MCS Mental Health Component Score
  9. MHI-5 Mental Health Inventory
  10. NDC New Deal for Communities
  11. NMSC Neo-Marxian Social Class
  12. PPL Paid Parental Leave
  13. S Suicide
  14. SES Socio-Economic-Status
  15. SF Short Form health survey
  16. SF-36 Short Form health survey (36 items)
  17. WHO-5 World Health Organization Well-Being Index
  18. aStudy measured depression only in the third wave of the study, so the sample which included MH consisted of 23 countries and 6603 participants
  19. bIncludes Sweden
  20. clooks at austerity