The research team, led by Sarah Derveeuw and Eva Gezels of Ghent University’s Department of Public Health and Primary Care, together with colleagues at the Centre for Cancer Detection in Bruges, took advantage of a rare scientific resource: individually linked population registry, cancer registry, health insurance and administrative socioeconomic records. Rather than surveying a sample and hoping it represents the whole, the investigators assembled a retrospective cohort of essentially every eligible woman aged 31 to 64 residing in Flanders between 2018 and 2023. This population-wide design eliminates the selection biases that plague smaller studies and allows researchers to detect patterns in groups that are often too small or too hard to reach for conventional surveys, including women who never interact with the health system at all.

The study’s central outcome was deliberately strict. A woman was classified as a long-term non-attender if she had no registered cervical screening test of any kind during the entire six-year observation window, a period spanning more than two full screening rounds under Flemish guidelines. Among the 1,220,227 women with complete data, 21.5 percent fell into this category. That figure is striking on its own, but the true analytical power of the study lies in how the researchers dissected it. They organised their analysis around Andersen’s Behavioural Model of Health Services Use, a long-standing framework that sorts the drivers of healthcare utilisation into predisposing factors such as age, migration background, household type, education and occupation; enabling factors such as household income, subsidised insurance status, recent childbirth and contact with a general practitioner; and illness-level factors such as chronic disease and major invalidity.

Using hierarchical multivariable logistic regression, the team estimated the odds of long-term non-attendance associated with each factor while adjusting for all the others, a statistical technique that isolates the independent contribution of every variable. The results delivered an unambiguous headline: nothing predicts screening behaviour better than whether a woman is already plugged into the healthcare system. Women who had recently given birth had 63 percent lower odds of long-term non-attendance compared with other women, with an odds ratio of 0.37, almost certainly because pregnancy and childbirth funnel them through routine medical contacts where screening can be offered or performed. Frequent contact with a general practitioner produced a similar protective pattern, with an odds ratio of 0.54. In other words, every additional touchpoint with primary care appears to act as an implicit gateway to cancer prevention, and women who lack those touchpoints are systematically left behind.

Education emerged as the most powerful socioeconomic determinant, and it did so in a classic gradient. Women with the lowest educational level had 79 percent higher odds of never attending screening across six years compared with the highest-educated group, an odds ratio of 1.79 that remained essentially unchanged after full statistical adjustment. The persistence of this gradient is important because it suggests that education captures something more fundamental than income alone, perhaps health literacy, familiarity with preventive medicine, the ability to navigate administrative systems, or the cultural capital to feel entitled to ask for preventive care. Intriguingly, household income told a much weaker story, showing only a modest and non-graded association with non-attendance. This dissociation between income and education is a technical finding with real policy consequences: simply making screening free or cheap, which Belgium already does, does not neutralise the social stratification of participation.

The study also produced one of its most nuanced results in the domain of migration background. Among first-generation migrant women, those born outside Belgium, elevated odds of non-attendance were largely attenuated once socioeconomic factors were taken into account, implying that their lower participation is substantially explained by the socioeconomic positions they occupy rather than by their origin per se. But the same was not true for the second generation, women born in Belgium to migrant parents. Elevated odds persisted among second-generation women of Maghrebi, Turkish, Asian, Sub-Saharan African and Eastern European origin even after adjustment for education, occupation, income and healthcare contact. That residual excess risk, surviving a battery of statistical controls, points toward mechanisms that administrative data cannot fully capture, including experiences of discrimination, cultural norms around intimate examinations, language and trust, and the specific ways healthcare services are perceived and navigated by ethno-racially minoritised communities.

Several other groups carried independently elevated odds of long-term non-attendance. Older women within the eligible age range were less likely to attend than younger ones, a pattern with direct biological relevance because the risk of cervical cancer and the persistence of high-risk human papillomavirus infections both increase with age. Women living alone had higher odds than those in larger households, consistent with the idea that partners and family members often prompt and accompany preventive care. Receiving an increased reimbursement, the Belgian marker of low income and financial vulnerability, was associated with non-attendance, as were chronic illness and major invalidity status. The latter finding may seem counterintuitive, since chronically ill patients see doctors frequently, but it likely reflects a clinical reality in which care becomes dominated by the presenting condition and preventive services fall by the wayside, a phenomenon researchers describe as preventive care crowding-out.

What makes this study methodologically significant is not only its scale but its data architecture. Linking the national population registry to the Belgian cancer registry, health insurance claims and administrative socioeconomic records allowed the researchers to construct a near-complete picture of each woman’s social circumstances and healthcare behaviour without asking anyone a single question. The authors handled missing data transparently, reporting characteristics for the full population of 1,283,569 women before restricting to complete cases, and they formally assessed multicollinearity among predictors using generalised variance inflation factors, ensuring that the large odds ratios they report are not statistical artefacts of correlated variables. The study was conducted under ethical approval from the Belgian Information Security Committee using pseudonymised data in compliance with the European General Data Protection Regulation.

The implications reach well beyond Flanders. Organised screening programmes, in which women are invited by name at regular intervals, were designed precisely to flatten social gradients in participation, and the Flemish data show that such programmes reduce but do not erase them. The authors argue that equity-oriented strategies should prioritise the women who remain systematically unreached: those with few socioeconomic resources, limited engagement with primary care, and second-generation migrant backgrounds. Concretely, that could mean embedding screening invitations in maternity and postnatal care, training general practitioners to opportunistically offer cytology or human papillomavirus testing during unrelated consultations, deploying self-sampling kits that women can use at home, and designing outreach that is culturally attuned rather than merely translated.

The study also carries a warning for the HPV vaccination era. As vaccinated cohorts age into screening programmes, maintaining high participation among the socially disadvantaged becomes even more critical, because unvaccinated women are not evenly distributed across society and tend to cluster in the very groups least likely to attend. The researchers are careful to note that their work identifies who is left behind, not why, and they call for further research into the specific mechanisms and barriers underlying these inequities to guide tailored programme adaptations. But the population-level message is already clear: a screening programme is only as equitable as its reach, and in Flanders, as in much of the world, that reach still stops short of the women who need it most.

Subject of Research: Sociodemographic and healthcare-access determinants of long-term non-attendance in cervical cancer screening in Flanders, Belgium

Article Title: Determinants of long-term non-attendance in cervical cancer screening in Flanders, Belgium: a retrospective population-wide cohort study using administrative data

Article References: Derveeuw, S., Gezels, E., Hendrickx, M., Kellen, E., Toma, S., Vanthomme, K., & Willems, S. (2026). Determinants of long-term non-attendance in cervical cancer screening in Flanders, Belgium: a retrospective population-wide cohort study using administrative data. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03056-x

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03056-x

Keywords: cervical cancer screening, health inequities, social determinants of health, Flanders, Belgium, population-based cohort, Andersen behavioural model, migration background, primary care, HPV, cancer prevention, public health

The research team, led by Jesper Löve of the University of Gothenburg together with colleagues including Gunilla Priebe, Bo Burström, Ailiana Santosa, and Nawi Ng, drew on the SCIFI-PEARL database, a nationwide register platform that links national and regional records on notifiable diseases, hospitalisations, causes of death, and socioeconomic circumstances. Their dynamic cohort covered the entire adult population of Sweden, some eight million people aged 18 and older, followed from March 2020 to March 2022. Over that period the registers recorded 67,997 COVID-19 hospitalisations and 15,895 deaths, corresponding to 84.3 hospitalisations and 19.7 deaths per 10,000 population.

What distinguishes the study is its method. Rather than treating each social factor separately, the researchers used an approach known as Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy, or MAIHDA, which is grounded in intersectionality theory. The framework, first articulated by legal scholar Kimberlé Crenshaw in 1989, holds that social categories such as gender, class, and migrant status do not operate in isolation but mutually shape one another within systems of privilege and oppression. The team combined five dimensions — age group, sex, income relative to the at-risk-of-poverty threshold, educational attainment, and birthplace classified by the World Bank income level of the country of origin — into 80 distinct intersectional strata, and modelled individuals nested within those strata.

The statistical logic is elegant. A first, unadjusted model estimates how much of the total variation in outcomes is attributable to the intersectional strata, expressed as the intraclass correlation coefficient. A second model adds all five defining dimensions as fixed main effects; if no interactions existed between the dimensions, all between-stratum variance would be explained and the random effects would vanish. Whatever variance remains points to intersectional interactions beyond the simple sum of each characteristic’s effect. This structure also partially pools information across strata, stabilising estimates for small or sparsely populated combinations — a decisive advantage over saturated interaction models that become unstable when many dimensions are crossed at once.

The results were striking. Intersectional strata explained a substantial share of the variance in outcomes, particularly for mortality among adults under 70, where intraclass correlations reached 25 percent in the first wave, 15 percent in the second, 17 percent in the third, and 22 percent in the fourth. For hospitalisation, the corresponding figures ranged between 7 and 14 percent depending on age group. Among people aged 70 and older, by contrast, the strata explained less of the variation — typically at or below 10 percent — suggesting that biological susceptibility and frailty dominated severe outcomes in old age, whereas in younger adults the patterns more clearly reflected socially structured differences in exposure, living conditions, and access to protective resources.

The most severe risks clustered in specific and sometimes unexpected combinations. During the first wave, hospitalisation among older migrants born in low-income countries was roughly four times higher than among their counterparts born in high-income countries. Older men born in low-income countries with low income and low education recorded hospitalisation rates as high as 3,550 per 10,000 in wave one. Yet the study repeatedly found that broad labels concealed enormous heterogeneity. Among older men born in low-income countries, first-wave mortality ranged nearly fourfold, from 346 to 1,377 per 10,000, depending on income and education. In some waves, migrants in advantaged strata fared better than certain Swedish-born men with low income and low education, who themselves appeared among the ten highest-risk strata in three of the four waves.

Equally important was the finding that vulnerability was temporally fluid. No single stratum occupied the highest-risk position across all four waves. In the first two waves, the ten highest hospitalisation strata among younger adults consisted exclusively of migrant men, but by wave three upper-middle-income-country-born women with low income and low education had joined them, and by wave four migrant women filled five of the ten highest positions. Mortality showed even greater fluctuation: among low-income, low-educated men born in low-income countries, rates fell from 44 per 10,000 in the first wave to 6, 18, and 7 per 10,000 in subsequent waves, a trajectory the authors link to shifting viral variants, the vaccination rollout, and evolving policy conditions.

One particularly revealing interaction emerged among younger men born in low-income countries who had high educational attainment but low income. The usually protective effect of education reversed in these strata — a pattern the authors attribute to the well-documented occupation–education mismatch experienced by many migrants in Sweden, whereby highly educated immigrants are over-represented in essential, high-exposure occupations. Overall, however, most inequalities followed an additive pattern, best described as ‘double jeopardy’, in which each marginalised position adds to disadvantage, rather than the compounded ‘multiple jeopardy’ of effects beyond additivity.

The authors are careful to stress that intersectional strata are analytical constructs, not inherent risk groups. As they and other scholars note, identifying categories as stand-alone risk factors risks diverting attention from the structural processes — crowded housing, high-risk work, inadequate health information, institutional distrust — that actually produce vulnerability. The pandemic, they argue, was a syndemic in which viral exposure interacted with pre-existing medical and social inequalities, and Sweden’s early reliance on voluntary recommendations and individual responsibility may have interacted differently with the social and occupational conditions of different groups.

The study’s implications reach well beyond Sweden. Because vulnerability shifted across pandemic phases and social positions, the authors conclude that pandemic preparedness cannot rely on static assumptions about ‘high-risk’ groups. Surveillance and interventions, they argue, should be responsive to changing patterns of inequality across intersecting social positions, and reducing the inequitable consequences of future pandemics will require not only intersectionality-informed monitoring but political commitment to addressing the structural conditions — living circumstances, social protection, and pre-existing health burdens — that make some people far more exposed than others when a new pathogen arrives.

Subject of Research: Intersectional inequalities in COVID-19 hospitalisation and mortality across four pandemic waves in Sweden, analysed with multilevel intersectional methods.

Article Title: Intersectional Inequalities in COVID-19 Hospitalisation and Mortality: A Nationwide MAIHDA Study of Swedish Adults Across Four Pandemic Waves (2020–2022)

Article References: Löve, J., Priebe, G., Burström, B., Santosa, A., & Ng, N. (2026). Intersectional Inequalities in COVID-19 Hospitalisation and Mortality: A Nationwide MAIHDA Study of Swedish Adults Across Four Pandemic Waves (2020–2022). SSM – Population Health, Article 101968. https://doi.org/10.1016/j.ssmph.2026.101968

Image Credits: AI Generated

DOI: 10.1016/j.ssmph.2026.101968

Keywords: COVID-19, intersectionality, MAIHDA, health inequalities, Sweden, hospitalisation, mortality, pandemic waves, migration background, socioeconomic status, public health, pandemic preparedness

The intervention, known by its Dutch wordplay name that translates roughly as “They Are Not Mental?!” (TANM), was designed to strengthen the resilience of informal caregivers with a migration background whose loved ones live with a suspected mental illness. It pursued three short-term goals: encouraging open conversations about mental health taboos, improving understanding of mental illnesses and available support, and fostering trust between migrant families and the healthcare sector. The program unfolded in three phases. First, four coordinating organizations recruited and trained voluntary “ambassadors”—peer educators who shared participants’ migration backgrounds and, in some cases, their caregiving experiences. Second, ambassadors facilitated three peer education sessions, delivered in the dominant language of each group, covering mental health and the role of culture, specific conditions such as schizophrenia and depression, and the role of family alongside formal support options. Third, caregivers identified during the sessions could be referred for tailored follow-up support, either in group training or one-on-one consultations with a Family-Experience-Expert, a professional who draws on personal lived experience of caring for someone with mental illness.

What makes the new study methodologically interesting is its realist evaluation design. Rather than simply asking whether TANM succeeded, the researchers, led by Malin H. L. Hollaar of Erasmus University Rotterdam, asked how, for whom, and under what circumstances it worked. Realist evaluation, developed by Pawson and Tilley, models outcomes as the product of Context-Mechanism-Outcome (CMO) configurations: specific contextual conditions activate specific mechanisms, which in turn generate outcomes. The team began with an Initial Program Theory built from twelve interviews and a focus group, then tested and refined it during the 2024–2025 implementation period using 27 semi-structured interviews with ambassadors, participants, and program staff, 10 observations of peer education sessions, and 76 anonymous post-session questionnaires. During this cycle, 11 ambassadors facilitated 11 groups attended by 138 participants, most of them women, with considerable variation in age, cultural background, and caregiving experience. Abductive and retroductive reasoning moved the analysis back and forth between the data, the initial theory, and concepts such as social learning, ultimately producing ten refined CMO-configurations validated in a focus group with the coordinating organizations.

The first cluster of findings concerns the taboo on mental illness itself. Nearly half of the participants—47.3 percent—reported experiencing a taboo around mental illness, with no significant differences between cultural groups, suggesting that shame and silence are not the property of any single community. Yet the degree to which groups became more open varied substantially, and the explanation lay in context. Groups whose ambassadors were already acquainted with participants, shared their language and cultural background, and remained available beyond the formal sessions were noticeably more open and engaged. In unfamiliar groups, conversations stayed reserved. Questionnaire analyses confirmed significant associations between prior acquaintance and the sharing of personal experiences, reinforcing that familiarity is not a soft nicety but a structural condition of disclosure.

The mechanisms behind this openness were fundamentally relational. Ambassadors worked as trusted peers, sharing reliable information while acknowledging alternative explanations for mental illness—including attributions to black magic, divine punishment, or the evil eye—rather than dismissing them. Trust emerged as the prerequisite for everything else, a point program staff emphasized by noting that shame and taboo exist in all cultures, and that the only way around them is building enough comfort for people to speak. Ambassadors deliberately engineered safety: setting explicit confidentiality rules, or encouraging indirect sharing. One ambassador described a participant who asked questions “on behalf of a friend” for two full sessions before revealing in the third that the friend was herself. Another described modeling vulnerability—sharing her own experiences or relatable anecdotes—which could trigger a domino effect of disclosures across the group, provided a basic level of trust was already in place.

The second cluster of findings addressed the bridge between informal family care networks and formal healthcare services. Ambassadors recruited participants through their peer role, enabled by their social capital and connections in both formal and informal networks. Recruitment strategies mattered enormously: ambassadors who drew on their own existing community groups or used one-to-one invitations generated many more referrals to the follow-up support phase than ambassadors who appeared as guest speakers in unfamiliar groups. Cultural alignment even shaped how the intervention was introduced. Some ambassadors framed the sessions as discussions about “taboos” rather than naming mental illness upfront, given the cautiousness such topics provoke. The researchers also found that TANM’s Dutch title lost its stigmatizing-ironic wordplay among non-native speakers—its primary target audience—an unexpected barrier to communication.

Clusters three and four traced the path to actual help-seeking and the unexpected role of social support. Before participants could seek help, many first had to recognize themselves as informal caregivers at all, since in many cultures caregiving is framed as a natural family duty rather than a distinct role, and seeking outside help can feel like failing that duty. Overcoming fear and distrust toward formal institutions—including fear that a child might be removed from the home, or wariness rooted in earlier negative encounters with providers—required trusted, independent-seeming guides such as ambassadors and the Family-Experience-Expert. Knowledge of the Dutch care system was transmitted through shared frames of reference, allowing ambassadors to contextualize advice in culturally recognizable terms; one ambassador explained how she could understand a participant consulting an imam or receiving ruqya, a form of spiritual healing involving Quranic recitation, and build on it rather than dismissing it. Strikingly, the researchers discovered that some participants joined primarily for social connection and emotional support rather than information, revealing a psychosocial spillover effect the intervention’s designers had not anticipated. In some cases, peer contact continued long after the formal sessions ended.

The study’s implications cut two ways. On one hand, the findings demonstrate that “being a peer” is not a fixed identity but a relational position constructed through shared culture, language, religion, or lived experience—which explains why the Family-Experience-Expert, whose similarity to participants was experiential rather than cultural, could build trust just as effectively. The ambassadors’ role modeling aligns closely with Bandura’s social learning theory: participants adopt behaviors when demonstrated by someone perceived as similar to themselves, and continued availability reinforces that change over time. On the other hand, this centrality exposed a structural vulnerability. Ambassadors described their roles as demanding, emotionally taxing, and extending well beyond the intervention period without supervision, structural support, or adequate compensation—a pattern documented previously among peer educators in HIV/AIDS prevention and workplace mental health. The researchers recommend structured support and fair compensation for ambassadors, mechanisms for transferring the Family-Experience-Expert’s experiential knowledge rather than concentrating it in a single person, and recruitment through ambassadors’ own groups or individual invitations rather than guest-speaking arrangements.

Perhaps the most sobering conclusion is that even a well-designed, culturally sensitive intervention cannot close the gap alone. Persistent structural barriers—language difficulties, jargon-heavy communication, culturally insensitive practices, and negative past experiences with care professionals—continued to shape participants’ trust and help-seeking, and these lie largely beyond the scope of any peer education program. The authors are explicit that interventions like TANM are a necessary but partial response, effective only when accompanied by system-level investment in culturally sensitive communication and care practices. Future evaluations, they argue, should track longer-term outcomes such as resilience and sustained help-seeking, and researchers working with underserved groups should ask whether the barriers lie within communities or within the research approaches themselves. For migrant caregivers navigating stigma, fear, and family expectations, the study suggests that the most powerful lever remains deceptively simple: someone like them, available over time, who understands both languages—the literal one and the cultural one.

Subject of Research: Realist evaluation of a peer education intervention supporting migrant informal caregivers of people with mental illness in Rotterdam.

Article Title: Navigating Stigma and Support: Realist Evaluation of Support for Migrant Informal Caregivers of Loved Ones with Mental Illness

Article References: Hollaar, M. H. L., Buis, P., Smedts, M., Uysal-Bozkir, Ö., Kocken, P. L., & Denktaş, S. (2026). Navigating Stigma and Support: Realist Evaluation of Support for Migrant Informal Caregivers of Loved Ones with Mental Illness. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01728-0

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01728-0

Keywords: informal caregivers, migration background, mental illness, peer education, realist evaluation, stigma, trust, resilience, help-seeking, culturally sensitive care, social support, Rotterdam