IntroductionPrevious studies have identified socioeconomic inequalities in the treatment of depression. However, these studies often take a narrow approach, focusing on a single treatment type and lacking a comprehensive theoretical framework. Moreover, income and education are frequently used interchangeably as indicators of disadvantage, without distinguishing their unique impacts. This study argues that relying solely on income to explain treatment inequalities is overly simplistic, suggesting instead that education influences treatment through two distinct pathways. The study’s objectives are twofold: first, to investigate the presence of a social gradient in depression treatment, and second, to examine how this gradient is manifested.MethodsThis study utilizes data from the Belgian Health Interview Survey (BHIS), covering four successive waves: 2004, 2008, 2013, and 2018. The weighted data represent a sample of the adult Belgian population. Multinomial regression models are used to address the research aims, and models are plotted to detect trends over time using marginal means post-estimation.ResultsFindings indicate that income is not significantly related to depression treatment, while persistent educational inequalities in treatment are observed over time. Individuals with longer educational attainment are more likely to use psychotherapy alone or a combination treatment, whereas individuals with shorter educational attainment are more likely to use pharmaceutical treatment alone.DiscussionThis study demonstrates that education plays a critical role in fostering health-related knowledge and reasoning, making individuals with longer education more likely to engage in rational health behaviors and choose more effective treatments, even when these treatments require more effort and competencies. The findings underscore the importance of considering education as a key determinant of depression treatment inequalities.

Background The COVID-19 pandemic underscored the issue of vaccine hesitancy, leading researchers to study the determinants of people's willingness to receive the COVID-19 vaccine. This study is the first to comprehensively investigate the role of preventive practices at both the individual and contextual level, drawing on the theoretical concept of “cultural health capital”. Methods Utilizing data from the Survey of Health, Ageing, and Retirement (SHARE), covering information from 18,454 individuals aged 50 years and above residing in 25 European countries, we examined the influence of past engagement in preventive practices and the prevalence of such practices within a country on the likelihood of COVID-19 vaccine uptake. Our analysis included (i) previous vaccination behaviors, (ii) other healthcare-related behaviors, and (iii) lifestyle factors at both the individual and contextual levels. Leveraging the longitudinal design of the SHARE, we accounted for the temporal ordering of the relationships. Results At the individual level, almost all preventive behaviors were significantly related to people's willingness to receive the COVID-19 vaccine. Individuals who (i) had received an influenza vaccination prior to the COVID-19 outbreak and during childhood, (ii) had regularly participated in dental and blood pressure check-ups throughout their lives, and (iii) did not engage in lifestyle-related risk behaviors, were more likely to accept the COVID-19 vaccine. Notably, alcohol use was not significantly associated. At the contextual level, only the vaccination coverage rate for influenza was found to be robustly related, indicating that individuals were more inclined to receive the COVID-19 vaccine in countries with higher influenza vaccination rates prior to the pandemic. Conclusion Active participation in preventive practices and effective implementation of vaccination campaigns can contribute to the development of (institutional) cultural health capital, which ultimately promotes a greater willingness to get vaccinated against COVID-19.

Purpose/Aim This study aims to translate and adapt the Personal and Perceived Public Stigma Beliefs Scale from the Eurobarometer into Urdu, subsequently modifying and evaluating its psychometric properties among Pakistani adolescents and young adults. Methods 1328 college students aged 15–24 from Layyah, Punjab, Pakistan participated in this cross-sectional study, using the stigma beliefs scale to measure attitudes toward mental illness. Results The Urdu version demonstrated good internal reliability (α = 0.76 for personal and 0.74 for perceived public stigma beliefs). Confirmatory factor analysis indicated acceptable indices, with loadings from 0.52 to 0.74 for personal and 0.46 to 0.71 for perceived public stigma beliefs. A significant positive correlation was found between personal and perceived public stigma beliefs and perceived public social distancing and services stigma. Conclusion The Urdu version of the modified Stigma Beliefs Scale has reliable psychometric characteristics for evaluating attitudes toward mental illness among Pakistani adolescents and young adults.

Chronic pain, as a barometer of population health, remains understudied from a socio-structural lens. This study adopts a life course perspective and integrates hukou as a potential institutional arrangement shaping pain, aiming to advance the understanding of health inequalities in China. Specifically, we examine urban-rural disparities in pain prevalence and investigate how these disparities evolve across the life course by using generalized estimating equations and the China Health and Retirement Longitudinal Study 2011-2020 (N = 16479). Our findings indicate that rural hukou holders experience more pain than their urban counterparts. Among rural hukou holders, urban dwelling is associated with a reduced pain risk. Furthermore, we observe that pain prevalence increases with age, yet such pain trajectories vary across urban and rural populations, showing a converging trend in pain over the life course. This study extends the literature on health inequalities by demonstrating how institutional and geographic characteristics jointly shape urban-rural gradients in pain prevalence. Moreover, it provides novel evidence for the age-as-leveler hypothesis in a non-Western context.

Aims: The Red Noses Culturally-Sensitive Stigma Survey (RN-CSS) contributes to the underexplored research domain of adolescents’ stigmatising attitudes and behaviours towards peers with mental health difficulties and mental healthcare services. It also addresses the need for comprehensive and culturally-sensitive tools to assess stigma in this context. Methods: Drawing on insights from focus groups and building upon the existing Stigma in Global Context-Mental Health Study, we have successfully developed and implemented the first culturally-sensitive stigma survey tailored for school-aged adolescents of different migration/cultural backgrounds. The questionnaire includes an unlabelled case vignette depicting a peer with symptoms of depression and gathers data on various domains, including (1) sociodemographic variables; (2) education-related information; (3) COVID-19; (4) perceptions of mental health difficulties and mental healthcare services (i.e. severity assessment, causal attributions, care recommendations, personal stigma, perceived stigma, and service stigma); (5) subjective wellbeing and familiarity with mental health difficulties; (6) social support; (7) school context; (8) bullying; and (9) knowledge of anti-stigma campaigns. Results: Our final sample comprises 5075 pupils from 38 secondary schools in Flanders, Belgium. Conclusions: In this article, we present the study’s background and rationale, the development of the questionnaire, and the sampling and recruitment methods employed. Furthermore, we provide a summary of the sample characteristics and preliminary descriptive results of the RN-CSS. Subsequent empirical studies will address the research objectives outlined in this protocol paper. The research opportunities provided by the developed materials and dataset are being discussed.

Building on the stress process model and adopting an intersectionality framework, this study highlights the formation of a stronger intergenerational family symbiosis system in China. It offers a systematic understanding of the association between multigenerational caregiving and sandwich women's stress, extending prior research by exploring the mitigating effect of husbands. Drawing upon China Health and Nutrition Survey data, findings indicate that sandwich women experience less stress than non-sandwich women. Particularly among sandwich women, upward care has a stress-reducing impact, while downward care has a stress-enhancing impact compared with carefree sandwich women. Providing active dual care has no significant effect, but when active help shifts to passive need, sandwich women's stress reaches a peak. Husbands living at home could not buffer wives' stress. These analyses depict the vulnerability of Chinese sandwich women under the revival of patriarchy and the imbalanced population structure and warrant a sounder public care system.

This study investigates the impact of the overall intensity and changes in grandparental caregiving on loneliness in grandparents in European countries. Data from waves 5 to 8 of the Survey on Health, Ageing, and Retirement in Europe (SHARE) were used (N(individual)s = 30,896 and N-observations = 48,562). We included grandparents (aged 50 years and over) with at least one grandchild at the beginning of the study. The analyses reveal that any intensity of grandparental care decreases the risk of loneliness. When looking at changes in grandparental care the results show that stable caregiving roles appeared to reduce loneliness, while starting to provide grandparental care makes grandparents more vulnerable to loneliness. In conclusion, our findings underscore that consistent grandparental care is important for grandparents in mitigating loneliness, highlighting the importance of sustained caregiving roles over fluctuations in caregiving intensity.

Studies to date have predominantly focused on countries' socioeconomic conditions (e.g., income inequality) to explain cross-national differences in socioeconomic inequalities in adolescent health (behaviours). However, the potential explanatory role of sociocultural contexts at country-level remains underexamined. This study examined whether the country-level sociocultural context and changes thereof were associated with adolescent socioeconomic inequalities in dietary behaviours. International comparative data of 344,352 adolescents living in 21 countries participating in 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey were combined with aggregated levels of openness-to-change from the European Social Survey (ESS). Four dietary behaviours (i.e., fruit, vegetable, sweets and soft drink consumption) and two measures of socioeconomic status (SES) on the individual level (i.e., family affluence scale [FAS] and occupational social class [OSC]) were studied. Multilevel logistic regression analyses returned contrasting results for the two SES measures used. In countries with higher levels of openness-to-change, smaller FAS inequalities in daily fruit, sweets and soft drink consumption were observed, but no such inequalities were found for vegetable consumption. Conversely, in these countries, larger OSC inequalities in soft drink consumption were found. Country-specific changes in openness-to-change over time were not associated with the magnitude of adolescent dietary inequalities. Findings underscore the importance of including country-level sociocultural contexts to improve the understanding of cross-national differences in socioeconomic inequalities in adolescents’ diets. Future studies, spanning a longer timeframe, are required to examine whether such associations exist within countries over time since our timeframe might have been too small to capture these long-term trends.

AIMS:socNAMs provides a comprehensive and comparative dataset for researchers to identify how students' recent migration and their school setting relates to their social wellbeing, particularly regarding their feelings of loneliness. Results: This study design article delineates a quantitative cross-sectional research study (socNAMs) which successfully developed three questionnaires that were administered with unique and hard to reach populations, newly-arrived adolescent migrants (NAMs) and school staff offering reception education in Flanders, Belgium. METHODS:At the individual level, socNAMs collected information on: (1) socio-demographic variables of NAMs; (2) migration and family context; (3) social relationships; (4) school experiences; (5) self-perceived wellbeing (physical and social); and (6) experiences with discrimination. The questionnaire developed for NAMs is available in 16 languages. To gain a further understanding of the impact of the school environment on NAMs, socNAMs collected contextual information primarily concerning school social capital by including data collected from teachers and reception-class coordinators. The final sample included 1379 NAMs, 50 teachers and 26 reception-class coordinators, from 35 schools offering reception education. CONCLUSIONS:In this article, we present the rationale for this study, the methodology of sampling and recruitment, the development and content of the questionnaires, some preliminary descriptive results and the strengths and limitations of the study. Future empirical studies will address the research aims outlined in this protocol paper. In addition, we highlight the opportunities that the dataset provides for advancing research regarding the social wellbeing of NAMs in varying school and national contexts.

This study examines how different migration backgrounds-non-migrants, newly-arrived migrants, first-generation migrants, and second-generation migrants-affect the mental and social wellbeing of adolescents. Data from two cross-sectional surveys in 2022 in Flanders, Belgium, included 17,639 adolescents (52% boys; aged 11-19). We analysed the association between migration background and four outcomes: depression symptoms (WHO-5 Wellbeing Index), and general-, social-, and emotional-loneliness (Revised UCLA Loneliness Scale), whilst accounting for age and sex differences. Our findings indicate that migration background significantly influences all four outcomes. Newly-arrived migrants showed the highest likelihood of experiencing depression (OR = 2.08) and loneliness (general OR = 2.12; social OR = 2.32; emotional OR = 2.89), when compared to their non-migrant peers. Similarly, non-newcomer first-generation and second-generation migrants also faced a higher risk of depression and loneliness compared to non-migrants. This study highlights the persistent challenges that migration poses for adolescents' social and mental wellbeing, and the extreme vulnerability of newly-arrived migrants.

Abstract Background Using a causal inference framework, our study aimed to extend previous work in providing a comprehensive understanding of the role various social contexts across different levels can play in predicting adolescent dietary behaviours. Methods Data came from the 2017/18 Health Behaviour in School-aged Children (HBSC) survey in Flanders (Belgium). The sample included representative data from 8,702 adolescents in 165 schools. Social factors at individual-level (family meals, family, peer, student and teacher support) and at contextual-level (school culture of student and teacher support and school-level socioeconomic status [SES]) were considered. Multilevel logistic regression analyses were performed. Results At individual-level, family meals and family and student support were positively associated with fruit and vegetable consumption, family meals with sweet consumption too. Student and teacher support showed positive associations solely with fruit consumption. At contextual-level, adolescents attending schools with a lower school-SES demonstrated lower vegetable consumption. Culture of teacher support was negatively associated with sweets but also vegetable consumption. For culture of student support no associations were found. Conclusions The study mainly provide cues for strengthening family social ties as dietary health promotion initiatives, with some evidence supporting the role of beneficial peer and school social factors. Mixed results for contextual school-level social factors warrant further research to identify additional school-related influences on adolescent dietary behaviours to advance current understandings. Key messages • Family meals and support promote healthy eating in adolescents, emphasising the health promoting role of family social ties in dietary habits. • Mixed findings on school-level social factors call for more research on school health policies.

This article presents the design of a seven-country study focusing on childhood vaccines, Addressing Vaccine Hesitancy in Europe (VAX-TRUST), developed during the COVID-19 pandemic. The study consists of (a) situation analysis of vaccine hesitancy (examination of individual, socio-demographic and macro-level factors of vaccine hesitancy and analysis of media coverage on vaccines and vaccination and (b) participant observation and in-depth interviews of healthcare professionals and vaccine-hesitant parents. These analyses were used to design interventions aimed at increasing awareness on the complexity of vaccine hesitancy among healthcare professionals involved in discussing childhood vaccines with parents. We present the selection of countries and regions, the conceptual basis of the study, details of the data collection and the process of designing and evaluating the interventions, as well as the potential impact of the study. Laying out our research design serves as an example of how to translate complex public health issues into social scientific study and methods.

This study aims to contribute to the growing interest in the consequences of migration for loneliness by investigating the role of generational status across various age groups in countries with differing integration policies and attitudes towards immigrants. Using data from rounds 5, 6 and 7 of the European Social Survey, I conducted logistic multilevel models on a sample of 121,835 respondents aged 18 years and older, residing in 26 countries. Loneliness was assessed based on a single-item item question from the Center for Epidemiologic Studies of Depression scale. The findings suggest that individuals with a migration background are more likely to experience loneliness than those without. Within this group, I found that first-generation immigrants who arrived after the age of 18 are more vulnerable to loneliness than those who arrived earlier, although the latter still reported more loneliness than second-generation immigrants. Furthermore, migration-related inequalities in loneliness were greater among the youngest age group (18-34 years) and in countries with a more positive public stance towards immigrants. In sum, this study highlights the persistent challenges that migration poses for loneliness across generations and age groups, and emphasizes the need to extend research in this area beyond older adults. Moreover, it suggests that promoting a welcoming culture towards immigrants may have unintended consequences for loneliness gaps, but further research is needed to explain this observation.

A higher prevalence of depression is found among patients with a migration background within the Belgian population. Nevertheless, this group is underrepresented in ambulant and residential mental health care services. Since general practitioners (GPs) have a crucial gatekeeping role, this led some researchers to investigate the possibility of a provider bias influencing GPs' assessment and referral of depressed patients with a migration background. However, GPs' accounts may be influenced by wider professional discourses present at the policy level, which are inevitably linked to institutions regulating the conduct of GPs. Therefore, this study applied a Foucauldian discourse analysis (a) to identify broader professional discourses in Belgian policy documents regarding patients with a migration background and depression in general practices, (b) to examine how patients with a migration background are discursively positioned and (c) to investigate which different balances of power in the relationship between GPs and patients with a migration background are demonstrated in the identified discourses. We identified three recurring discourses: (a) the othering discourse, (b) the health literacy discourse, and (c) the person-centred discourse. Our analysis demonstrated that the former two discourses illustrate the perpetuation of a biomedical discourse. While the last discourse is aligned with a counter-discourse associated with the person-centred care model in health care. Consequently, our analysis demonstrated the construction of a contradictory discursive framework throughout the various policy documents on which GPs might rely when speaking about patients with a migration background suffering from depression.

Introduction:The use of psychotropics, such as benzodiazepine receptor agonists (BzRAs), among working-age adults in Belgium has shown educational differences. However, it is unclear how work status plays a role in this relationship. Therefore, this research aims to investigate whether work status explains observed educational differences in BzRA use. In addition, considering medicalisation processes, where non-medical factors, such as work status, are increasingly associated with medical mental health care-seeking behavior, this research also aims to investigate whether work status explains observed educational differences in BzRA use, regardless of mental health status.Methods:Data are obtained from the Belgian Health Interview Survey (BHIS). Four successive waves are covered: 2004, 2008, 2013, and 2018. The weighted data represent a sample of 18,547 Belgian respondents aged 18 to 65 years old. Poisson regression models are used to analyze the research aims. Time evolutions are plotted using marginal means postestimation.Results:The average use of BzRAs shows a slight decline over the waves studied (2004 = 5.99, 2008 = 5.88, 2013 = 5.33, 2018 = 4.31). Educational and work status differences in BzRA use are observed, regardless of mental health status. Individuals with longer education report lower use compared to individuals with shorter education, and individuals who are unemployed, (pre-)retired, or sick or disabled report higher use compared to employed individuals. Furthermore, work status acts as a mediator, partially explaining educational differences in BzRA use, regardless of mental health status.Discussion:Work-related uncertainty leads to increased prescribing and medication use, regardless of mental health. Medicalisation and pharmaceuticalisation processes detach social problems from their social roots and treat them as personal failures. The marginalization of the social roots of unemployment, sick leave and involuntary (pre-)retirement has led to a personalization of responsibility. Negative feelings arising from such work statuses may cause isolated, non-specific symptoms for which medical treatment is sought.

OBJECTIVES Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of the individual (e.g. age and ethnicity), interpersonal (e.g. healthcare provider trust), and organisational (e.g. perceived workload) factors on general practitioners (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with or without a MB. DESIGN An experimental study was carried out in which GPs were shown one of two video vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797, response rate was 13%) had to decide on their diagnosis, treatment, and referral. Analysis of variance and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables. RESULTS Overall, we found that there were ethnic differences in GPs' decisions regarding diagnosis and treatment recommendations. GPs perceived the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and demonstrated a reduced likelihood to prescribe a combination of medical and non-medical treatments (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was exaggerating his distress. CONCLUSION This paper showed that lower levels of trust among GPs' towards their migrant patients and high GP workloads contribute to an increased ethnic bias in medical decision-making. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs' trust in their migrant and ethnic minority patients.

The COVID-19 pandemic and related physical distancing measures have disproportionally affected older adults living alone due to their greater social isolation. Unlike previous studies on the subject, the current research recognizes the diversity amongst older adults living alone by considering the impact of marital history. Combining information from Wave 8 of the Survey of Health Ageing and Retirement (SHARE), with data of SHARELIFE and the SHARE Corona survey, we investigated the differential impact of the COVID-19 pandemic on loneliness in older men (N = 1504) and women (N = 4822) living alone. Logistic multilevel analyses were performed on data from 26 European countries and Israel. For men, we found that the short-term widowed were more likely to report increased loneliness than the medium- and long-term widowed and those living apart together (LAT). For women, the results indicated that the short- and medium-term widowed and the divorced were at greater risk for increased loneliness than those in a LAT relationship. Also, medium-term widowed women were more likely to report increased loneliness than their long-term widowed counterparts. The three hypothesized underlying mechanisms - i.e., (i) the opportunity mechanism, (ii) the expectation mechanism, and (iii) the vulnerability mechanism - only played a small role in explaining the observed differences. In sum, our study highlights the importance of recognizing the diversity within the group of older adults living alone when investigating the effects of the pandemic on loneliness, yet the mechanisms behind the stratifying role of marital history are not fully understood.

Abstract Background Although people with a migration background (MB) have more unmet mental health needs than the general population, patients with a MB are still underrepresented in mental health care services. Provider bias towards these patients has been evidenced repeatedly but its driving factors remain elusive. We assessed the moderating effect of individual (e.g. age and ethnicity), interpersonal (e.g. provider trust), and organizational (e.g. perceived workload) factors on general practitioners’ (GPs) differential decision-making regarding diagnosis, treatment, and referral for a depressed patient with a MB and for a depressed patient without a MB. Methods An experimental study was carried out in which GPs were shown one of two video-vignettes featuring adult male depressed patients, one with a MB and the other without. Belgian GPs (n = 797) had to decide on their diagnosis, treatment, and referral. ANOVA and logistic regression were used to analyse the effect of a MB, adding interaction terms for the explanatory variables. Results Overall, we found that there were ethnic differences in GPs’ decisions regarding diagnosis and treatment recommendations (F = 3.56, p < 0.001). GPs also considered the symptoms of the patient with a MB less severe (F = 7.68, p < 0.01) and were less likely to prescribe a combination of medical and non-medical treatment to patients with a MB (F = 11.55, p < 0.001). Those differences increased in accordance with the GP's age and perceived workload; at an interpersonal level, we found that differences increased when the GP thought the patient was malingering or exaggerating his distress. Conclusions This paper showed that GPs’ trust in their patients and GPs’ workload affect ethnic bias in medical decisions. This may perpetuate ethnic inequalities in mental health care. Future researchers should develop an intervention to decrease the ethnic inequities in mental health care by addressing GPs’ trust in their migrant patients. Key messages • This research provides an insight into the discriminatory decisions made by GPs in mental healthcare. • Future research should take interpersonal and organizational factors into account when developing new interventions to improve quality of care for migrants with mental health problems.

PURPOSE:Several studies have shown socioeconomic inequalities in psychotropic medication use, but most of these studies are inspired by Andersen's behavioural model of health care use, which strongly focusses on individuals' needs. Andersen's model pays little attention to health care use that is not based on need and insubstantially recognises the context dependentness of individuals. Medicalisation, however, is a context-dependent interactive process that not only interacts with need determinants, but also with non-need determinants that affect health care use. Therefore, this study will examine if psychotropic medication use is stratified, and whether this is not simply the result of differences in need for care, but also influenced by factors not based on need, initiating the stratified medicalisation of mental health symptoms.METHODS:Data from the Belgian Health Interview Survey (BHIS) are used. This study covers information from five successive waves: 2001, 2004, 2013, 2018. The weighted data represent a sample of the adult Belgian population. The research aims are analysed using stepwise Poisson regression models, where the models are also plotted to detect evolutions over time, using marginal means postestimation.RESULTS:The results reveal that educational inequalities in psychotropic medication use are significant and persistently visible over time. Even after entering need for care, educational inequalities remain significant.CONCLUSION:This study shows that psychotropic medication use is stratified and that this is not simply the result of differences in need for care, but also influenced by factors linked to the stratified medicalisation of mental health symptoms.

Abstract Background Patients with a migration background (MB) have more mental health disorders than those without migration background. Yet, those patients are still underrepresented in mental healthcare services and have more unmet medical needs. Although providers’ bias has been well studied, up to date, little is still known about the factors explaining those biases. We assessed the effect of general practitioners’ (GPs') individual and organizational factors on their decision-making regarding diagnosis, treatment and referral recommendations for patient with MB with symptoms of major depression. Methods An experimental study staged a video-vignette of a depressed patient with or without MB. GPs had to make decision about diagnosis, treatment and referral. We then assessed the influence of several factors on their decisions such as age, ethnicity, workload and patient confidence. ANOVA and MANOVA were used for analyses. Results Overall, we found more unfavourable decisions in GPs diagnosis and treatment recommendations regarding the patient with a MB (F = 3.56, p < 0.001). In addition, they considered the symptoms of the patient with a MB as less severe (F = 7.68, p < 0.01) and would prescribe less often a medical treatment to these patients (F = 4.09, p < 0.05). Nevertheless, few factors explained these differences, except the age, the workload and the patient trustworthiness. Conclusions This paper highlighted GPs biases based on apparent migration background of a patient with major depression that perpetuates ethnic inequalities in mental health care. Further research into the origins of discrimination in primary mental health care are needed to explain how and when those discriminations arise. Key messages • This paper shed light on pervasive unintentional discrimination still persist in mental health care among migrants in Europe. • These findings may help us to further understand the role of general practitioner behaviour in primary mental health care discrimination.