Role of Child Marriage and Adolescent Childbearing on Hysterectomy Among Married Women in India: A Cross-Sectional and Time-to-Event Analysis.

OBJECTIVE: Child marriage forces a girl into adult roles before physical and psychological maturity, which can take a toll on women's health over the life course. This article aims to assess whether child marriage and adolescent childbearing are associated with elevated risk of gynaecologic disorders leading to hysterectomy. DESIGN: Cross-sectional and time-to-event analysis. SETTING: India. POPULATION: 528 816 ever-married women, aged 20-49 years. METHODS: Women were grouped in four mutually exclusive categories: (i) married adult-not an adolescent mother (reference category), (ii) married adult-adolescent mother, (iii) married child-not an adolescent mother and (iv) married child-adolescent mother. Multivariable logistic regressions were fitted to assess the odds of hysterectomy for these groups. Nonparametric Kaplan-Meier survivor functions were estimated to evaluate survival rates across the groups. MAIN OUTCOME MEASURES: Whether had a hysterectomy and age when hysterectomy was performed. RESULTS: Compared to women married as adults, not an adolescent mother, women married in childhood and gave birth in adolescence were 1.87 (95% CI: 1.78-1.96) times more likely to have a hysterectomy. The latter group also had the lowest survival probability for hysterectomy at all ages (e.g., 85.80% [95% CI: 85.41-86.18] at age 49 years as compared to 91.65% [95% CI: 91.37-91.89] for the former group). Women married as children but not adolescent mothers and married as an adult but gave birth in adolescence also had higher odds of hysterectomy-1.40 (95% CI: 1.31-1.50) and 1.53 (95% CI: 1.40-1.66) times of that of the reference group, respectively. CONCLUSIONS: Our results, showing a strong relationship between child marriage and hysterectomy, contribute to the literature on later-life health consequences of child marriage.

Psychosocial well-being and firearm storage practices: evidence from five US states.

OBJECTIVE: Gun safety practices can play a pivotal role in preventing suicide and unintentional injuries involving a firearm. This study aimed to assess whether psychosocial well-being, measured by emotional support, feeling of social isolation and life satisfaction, influenced safe storage practices among individuals who had firearms in or around their home. METHODS: Data are from the firearm safety module of the 2022 Behavioural Risk Factor Surveillance System survey of 11 722 individuals having firearms and living in California, Minnesota, Nevada, New Mexico and Ohio. Respondents were asked to identify how guns were stored in their homes including: (1) not loaded, (2) loaded but locked and (3) loaded and unlocked. Multinomial logistic regression models with controls for sociodemographic correlates assess the relative risks of certain storage measures. RESULTS: Relative to the base outcome of not loaded, the adjusted relative risks of having firearms loaded and unlocked among individuals who usually/always felt socially isolated were 1.72 (95% CI: 1.02 to 2.88) times that of individuals who never felt socially isolated. The adjusted risks among individuals who were dissatisfied with their life were 1.82 (95% CI: 1.02 to 3.24) times that of their counterparts who were very satisfied. The adjusted risks were not statistically significant among individuals who rarely/never received needed emotional support compared with individuals who always received support. CONCLUSION: The results suggest a strong relationship between social isolation and life satisfaction and safe storage practices at home. Policies designed to improve psychosocial well-being, therefore, may present an important opportunity for preventing unintentional firearm injuries.

Cardiovascular conditions and obesity among gynecologic cancer survivors: Results from the 2020 behavioral risk factor surveillance system survey.

BACKGROUND: With the increasing prevalence of gynecologic cancer and obesity, there is a growing population living with cardiovascular disease, obesity and gynecologic cancer concurrently or at risk of developing these disease states. METHODS: We examined cardiovascular (CV) conditions and obesity among 1824 gynecologic cancer survivors in a cross-sectional analysis, using data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS). Univariate and multivariable logistic regression methods were used in the analysis. RESULTS: The prevalence of heart attack, CHD, and stroke were significantly higher (p < 0.001) among survivors of gynecologic and other cancer survivors compared to women with no history of cancer. However, no statistically significant differences were observed across gynecologic and other cancer survivors. The prevalence of obesity among gynecologic cancer survivors was significantly higher (p < 0.001) than that in the other two groups. While around one-third of the women with no history of cancer and survivors of other types of cancer were obese, obesity prevalence was nearly 13%-points higher among survivors of gynecologic cancer. In multivariate analysis, gynecologic cancer survivors were 2.7 times more likely to have a heart attack compared to those without any history of cancer. The odds of CHD and stroke among survivors of gynecologic cancer were respectively 3.4 and 2.7 times that of those with no history of cancer. The adjusted odds were also similar, though smaller in magnitude. Gynecologic cancer survivors were also more likely to be obese -1.8 times that of those with no cancer. CONCLUSIONS: Gynecologic cancer survivors are more likely than persons without a cancer history to have cardiovascular disease and other chronic illnesses, and they have a higher prevalence of heart attack, stroke, and obesity. These results underscore the sizeable opportunities for primary, secondary, and tertiary prevention of cardiovascular health conditions among gynecologic cancer survivors.

Predictors of unhealthy physical and mental days among informal cancer caregivers: results from the 2019 Behavioral Risk Factor Surveillance System survey.

BACKGROUND: Patients with cancer and cancer survivors commonly rely upon family members and friends to act as caregivers to help manage cancer treatment and the late effects of that treatment. Informal caregivers provide a variety of supportive functions for cancer patients, including emotional, informational, and functional support, and practical assistance with skilled care activities. OBJECTIVE: We examined predictors of unhealthy physical and mental days among informal cancer caregivers. Unhealthy days are an estimate of the overall number of days during the previous 30 days when the respondent felt that either his or her physical or mental health was not good. METHODS: Data were used from the 2019 Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional, population-based study. The participants were adults aged ≥ 18 years who provided regular care or assistance to a friend or family member who had cancer in the past 30 days. RESULTS: On average, caregivers who had a household income of less than $25,000 per year reported more (p < 0.05) unhealthy physical and mental days (during the last 30 days). Average reported number of mental unhealthy days was the highest for those who provided care for 2 or more years and 40 or more hours per week. Caregivers of Hispanic ethnicity had a greater risk of reporting unhealthy physical and mental days among those who provided care for 2 or more years. Among those who were providing care for 40 + h a week, caregivers from less wealthy households (income less than $50,000) were at greater risk of experiencing a larger number of unhealthy mental days. CONCLUSIONS: Informal cancer caregiving can be a stressful experience with potentially negative consequences for both psychological and physical health. Of particular concern are caregivers who are low-income or have limited financial resources.

Child marriage and risky health behaviors: an analysis of tobacco use among early adult and early middle-aged women in India.

BACKGROUND: Though the harmful impacts of child marriage have been evaluated across several domains, evidence on the relationship between child marriage and health behaviors over the life course is limited. In this paper, we examined whether getting married as a child is associated with one of the most common risky health behaviors, tobacco use, in adulthood. METHODS: Using nationally representative data from India, we compared the odds in favor of tobacco use among early adult (age 22-34) and early middle-aged (age 35-44) women who were married before age 18 with that of those who were married as youths (age 18-21). We estimated univariate and multivariable logistic regressions to obtain odds ratios in favor of any tobacco-use and relative risk ratios in favor of mutually exclusive types of tobacco use (smoking-only, smokeless-only, and dual-use). We also explored the intensive margin of the relationship by assessing if the odds of tobacco use in adulthood were affected by how early (13 or less, 14-15, or 16-17) a child bride was married. RESULTS: We find that the adjusted odds of tobacco use for those who were married as a child were 1.3 and 1.2 times that of those who were married as a youth among early adult and early middle-aged women, respectively. The younger was the child bride when married, the higher were the odds of tobacco use as an adult. The relative risks of different types of tobacco use were also higher for child brides than their peers. CONCLUSIONS: These results are the first evidence of the association between child marriage and a major risky health behavior, tobacco use, over the life course. These findings will inform policies to strengthen child marriage prevention efforts and targeted tobacco control initiatives in the low-and-middle income countries.

An analytical model of population level chronic conditions and COVID-19 related hospitalization in the United States.

BACKGROUND: The surge in the COVID-19 related hospitalization has been straining the US health system. COVID-19 patients with underlying chronic conditions have a disproportionately higher risk of hospitalization and intensive care unit (ICU) admission. We developed a retrospective analytical model of COVID-19 related hospitalizations and ICU admissions linked to each of the three major chronic conditions - hypertension, diabetes, and cardiovascular diseases (CVD). METHODS: Based on the differential probability of hospitalization of the COVID-19 patients with and without a chronic condition, we estimate a baseline cumulative hospitalization rate and ICU admission rate using the population level chronic condition prevalence from the 2019 Behavioral Risk Factor Surveillance System survey. Next, we estimate the hospitalization and ICU admission rates under an alternative scenario of a lower prevalence of the same chronic condition, aligned with the World Health Organization target of 25% relative reduction of prevalence by 2025. We then compare the outcomes of the baseline and the alternative scenarios. RESULTS: We estimate that the lower prevalence of hypertension would have lowered the cumulative hospitalization and ICU admission rates by more than 2.5%. The lower prevalence of diabetes and CVD would lower the cumulative hospitalization rate by 0.6% and 1.4% respectively. The decrease in the rates would have been relatively higher among Black and elderly (age 55+). CONCLUSIONS: Our model, thus, provides evidence on the importance of prevention, control, and management of chronic conditions to lessen the overwhelming financial and public health burden on the health system during a pandemic like the COVID-19.

Revisiting the association between worldwide implementation of the MPOWER package and smoking prevalence, 2008-2017.

BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

Uncontrolled hypertension among tobacco-users: women of prime childbearing age at risk in India.

BACKGROUND: Uncontrolled hypertension and tobacco use are two major public health issues that have implications for reproductive outcomes. This paper examines the association between tobacco-use status and uncontrolled hypertension among prime childbearing age (20-35) women in India. METHODS: We used the India National Family Health Survey (NFHS-4) 2015-2016 to obtain data on hypertension status and tobacco use for 356,853 women aged 20-35. We estimated multivariate logistic regressions to obtain the adjusted odds ratio for tobacco users in favor of having uncontrolled hypertension. We examined the adjusted odds at different wealth index quintiles, at different educational attainment, and at different level of nutritional status measured by body mass index. RESULTS: We found that the odds of having uncontrolled hypertension for the tobacco user women in India was 1.1 (95% CI: 1.01-1.19) times that of tobacco non-users at prime childbearing age. The odds were higher for tobacco-users at the poorest quintile (1.27, 95% CI: 1.14-1.42) and with no education (1.22, 95% CI: 1.10-1.34). The odds were also higher for tobacco-users who were overweight (1.88, 95% CI: 1.57-2.29) or obese (2.82, 95% CI: 1.88-4.24). CONCLUSIONS: Our findings highlight the disproportionate dual risk of uncontrolled hypertension and tobacco use among lower-income women of prime childbearing age, identifying an opportunity for coordinated tobacco control and hypertension prevention initiatives to ensure better health of reproductive-age women in India.

Hypertension in women: the role of adolescent childbearing.

BACKGROUND: Adolescent childbearing is associated with various health risks to the mother and child, and potentially with adverse socioeconomic outcomes. However, little is known about the role of adolescent childbearing in maternal health outcomes in adulthood. This study investigates the link between childbirth in adolescence and later-life risk of hypertension among women in India. METHODS: We obtained nationally representative data on demographic and health outcomes for 442,845 women aged 25 to 49 from the India National Family Health Survey (NFHS) 2015-16. We assessed the difference in hypertension prevalence between women who gave birth in adolescence (age 10 to 19) and those who did not, for the full sample and various sub-samples, using linear probability models with controls for individual characteristics, hypertension risk factors, and geographic fixed effects. RESULTS: Nearly 40% of the women in the sample gave birth in adolescence. The adjusted probability of being hypertensive in adulthood was 2.3 percentage points higher for this group compared to women who did not give childbirth in adolescence. This added probability was larger for women who gave birth earlier in adolescence (4.8 percentage points) and for women who gave birth more than once in adolescence (3.4 percentage points). CONCLUSIONS: Adolescent childbearing was strongly associated with a higher probability of adult female hypertension in India. This finding illustrates the intertemporal relationship between health risk factors during the life cycle, informing the importance of addressing adverse early life events (e.g. child marriage and adolescent childbirth) for hypertension outcomes among women in India.

Child marriage and exposure to secondhand smoke among women of childbearing age: evidence from a nationally representative study in India.

Women in low-and-middle income countries (LMICs) are disproportionately exposed to secondhand smoke (SHS), particularly in the home environment. Girls married before the age of 18 are more likely to remain at home and may be at higher risk of SHS exposure. This paper investigates whether women who were married as child brides had a higher risk of SHS exposure than their peers who were married as adults in India, where both burden of smoking and child marriage are critical public health concerns. Data were obtained from the 2015-2016 wave of the nationally representative India National Family Health Survey and included 306,788 married women ages 18 to 35 years. We estimated bivariate and multivariate logistic regressions to obtain odds ratios in favor of SHS exposure. The prevalence of SHS exposure for those who were married as adults was 50.3% while that was 55.2% for those who were married before age 18. After controlling for sociodemographic characteristics, the adjusted odds of SHS exposure for those who were married as child were 1.06 (95% CI: 1.03, 1.09) times that of those who were married as adults. Findings of this study inform policies for coordinated efforts to eliminate child marriage and strengthen tobacco control.

Tobacco control and household tobacco consumption: A tale of two educational groups.

Since the ratification of the World Health Organization Framework Convention on Tobacco Control in 2004, Pakistan has made modest but continued progress in implementing various tobacco control measures. By 2014, substantial progress was achieved in areas of monitoring, mass media antitobacco campaigns, and advertising bans. However, the findings from the 2014 Global Adult Tobacco Survey of Pakistan show significant differences in antitobacco campaign exposure among individuals of different educational attainment. Given this large variation in noticing antitobacco information, this paper analyzes how heterogeneity in treatment exposure may differentially impact tobacco-use prevalence across household groups. Household-level tobacco-use prevalence in 2014 was, respectively, 56% and 48% for the low- and high-education households. The gap in tobacco-use prevalence between the two educational groups further widens post 2014. We find that, on average, individuals with higher than primary education are 14 percentage points and 6 percentage points more likely to notice anticigarette and antismokeless tobacco information in 2014, respectively. Subsequently, in 2016, high-education households experienced a 3.6 percentage point higher reduction in tobacco-use prevalence compared to the low-education households. These findings motivate policies to enhance the outreach of tobacco control measures across different educational groups.

Carbonating the household diet: a Pakistani tale.

OBJECTIVE: Carbonated beverage consumption is associated with various adverse health conditions such as obesity, type 2 diabetes and CVD. Pakistan has a high burden of these health conditions. At the same time, the carbonated beverage industry is rapidly growing in Pakistan. In this context, we analyse the trends and socioeconomic factors associated with carbonated beverage consumption in Pakistan. DESIGN: We use six waves of the cross-sectional household surveys from 2005-2006 to 2015-2016 to analyse carbonated beverage consumption. We examine the trends in carbonated beverage consumption-prevalence for different economic groups categorised by per capita household consumption quintiles. We estimate the expenditure elasticity of carbonated beverages for these groups using a two-stage budgeting system framework. We also construct concentration curves of carbonated beverage expenditure share to analyse the burden of expenditure across households of different economic status. SETTING: Pakistan. PARTICIPANTS: Nationally representative sample of households in respective survey waves. RESULTS: We find that the wealthier the household, the higher is the prevalence of carbonated beverage consumption, and the prevalence has increased for all household groups over time. From the expenditure elasticity analysis, we observe that carbonated beverages are becoming an essential part of food consumption particularly for wealthier households. And, lastly, poorer households are bearing a larger share of carbonated beverage expenditure in 2014-2016 than that in 2006-2008. CONCLUSION: Carbonated beverages are becoming an increasingly essential part of household food consumption in Pakistan. Concerns about added sugar intake can prompt consideration of public health approaches to reduce dietary causes of the disease burden in Pakistan.

Assessing the relationship between out-of-pocket spending on blood pressure and diabetes medication and household catastrophic health expenditure: evidence from Pakistan.

BACKGROUND: Treatment of non-communicable diseases (NCDs) in low-and-middle-income countries (LMICs) is costly and could expose households to financial hardship and vulnerability. This paper examines the association between medication costs of two major NCDs - hypertension (blood pressure) and diabetes, and household-level incidences of catastrophic health expenditure (CHE) in a South Asian LMIC, Pakistan. METHODS: The study analyzes self-reported blood pressure and diabetes (BPD) medication expenditure from the latest version (2015-16) of the Household Integrated Economic Survey (HIES) of Pakistan, a nationally representative survey of 24,238 households. The incidence of CHE is defined as households' out-of-pocket (OOP) medical expenditure exceeding 10% of the total household expenditure. Using a linear probability model, we estimate the adjusted differences in CHE incidence between households that are spending and 'not' spending on BPD medication. We also analyze several hypothetical scenarios of BPD medication cost coverage, and compare the estimated CHE incidences of respective scenarios with the status quo. RESULTS: We find that the average monthly medical expenditure, and average medical expenditure share are significantly higher for households spending on BPD medication, compared to households 'not' spending. The incidence of CHE is found 6.7 percentage point higher for the households consuming BPD medication, after controlling for relevant socioeconomic attributes. If 25, 50, and 100% of the BPD medication OOP cost is covered, then the CHE incidence would reduce respectively by 5.9, 12.7, and 21.4% compared to the status quo. CONCLUSION: Medication cost for managing two major NCDs and household catastrophic health expenditure have strong associations. The findings inform policies toward ensuring access to necessary healthcare services, and protecting households from NCD treatment related financial hardship.

Long COVID and the Higher Risk of Food Insecurity Among Participants and Nonparticipants of Food Assistance Programs in the United States.

BACKGROUND: In the aftermath of the COVID-19 public health emergency, it is important to understand the extent of socioeconomic burdens of long COVID, defined as continuation of symptoms after initial infection, including food insecurity. OBJECTIVE: This study aimed to assess the association between long COVID and family food insecurity among low-income individuals (or any of their family members living with them) who were participants and nonparticipants in public food assistance programs (Supplemental Nutrition Assistance Program [SNAP], Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], and National School Lunch Program [NSLP]) in the United States. DESIGN: The study used an observational cross-sectional design. PARTICIPANTS/SETTING: Data on 7151 adults (aged 18+ years), with family income of < 200% of the Federal Poverty line, from the 2022 National Health Interview Survey, were analyzed. MAIN OUTCOME MEASURES: Level of family food security, based on responses to a set of 10 questions measuring family's food security during the past 30 days. STATISTICAL ANALYSES PERFORMED: Multinomial logistic regression models were estimated to obtain relative risk ratios of marginal and low/very low food security, relative to the base outcome of high food security, for long COVID status. Multivariable models were estimated separately for the full sample and for subgroups of food assistance participants and nonparticipants. A seemingly unrelated regression (SUR) specification was estimated to assess whether the estimates were different across the participant and nonparticipant subgroups. RESULTS: Compared with individuals who never had COVID-19, the adjusted relative risks of experiencing marginal and low/very low food security were 1.42 (95% CI, 1.00-2.02) and 1.43 (95% CI, 1.08-1.91) times higher, respectively, for individuals who had long COVID. Although the adjusted risks were not observed to be statistically significant in the participant subgroup, among nonparticipants, adjusted relative risk ratios were 2.34 (95% CI, 1.43-3.82) and 1.56 (95% CI, 1.02-2.39), respectively. SUR results showed that relationships between long COVID and food insecurity were only different for marginal and not low/very low levels of food security between food assistance participant and nonparticipant groups. CONCLUSIONS: Study findings highlight a significantly higher risk of marginal and low/very low- food security among low-income adults who had long COVID, especially those who were nonparticipants in public food assistance programs. Further research is warranted to explore the causal pathways of this relationship for informing policies to mitigate the burden of long COVID.

Health disparity at the intersection of religion and caste: Evidence from India.

Objective: The provisions and recognition of Schedule Castes (SCs), the constitutional term for the Dalits in India, have been exclusively extended to Hindus, Buddhists, and Sikhs (HBS). Omission of Dalit Muslims and Christians (MC) from the SC category stripped them of the affirmative action benefits tied with the SC status. This study aimed to explore how such differential treatment might play a role in differential health outcomes in Dalit women in India. Methods: Drawing data on 177,346 Dalit women, aged 20 to 49 years, from two successive nationally representative surveys, we assessed the differential likelihood of hypertension and diabetes, between MC- and HBS- Dalit women. Accounting for birth cohort-, survey wave-, and state of residence- fixed effects, along with socioeconomic conditions and cardiometabolic risk factors, we obtained adjusted odds of having hypertension and diabetes in MC women. To check the validity of our results, we conducted similar analyses using data on 170,889 Scheduled Tribe (ST) women, another marginalized group, whose ST-status recognition were not tied to religion. Results: We found that Dalit MC women were 1.13 (95% CI: 1.03-1.25) and 1.19 (95% CI: 1.05-1.36) times more likely to have hypertension and diabetes, respectively, compared to Dalit HBS women. Conversely, no statistically significant differential likelihood of these conditions was observed between MC and HBS women in the ST sample. Conclusion: Our investigation thus, indicated a potential link at the crossroads of religion and caste that may contribute to the health disparities among marginalized women in India.

Religious minority status and risk of hypertension in women: Evidence from Bangladesh.

Discrimination based on religion and communal violence against religious minorities have been on the rise worldwide. Despite growing incidences of violence against religious minorities, little is known on the relationship between minority status and population health outcomes in the low-and-middle income countries (LMICs). This study intends to fill this gap by assessing the prevalence of hypertension among religious minority women in Bangladesh, a South Asian country with high levels of social hostilities involving religion. Using data from the Bangladesh Demographic and Health Survey (BDHS) 2017-18, we examined whether religious minority women had a differential risk of having hypertension. We estimated logistic regression models to obtain the odds in favor of being hypertensive among women aged 18-49 years and compared the odds for religious minority women with that of their non-minority counterparts. We then estimated linear regression models to examine how average systolic- and diastolic-blood pressure measures differ across minority and non-minority women. We found that the odds of being hypertensive for minority women were 1.43 (95 % CI: 1.14-1.79) times that of their non-minority counterparts. The adjusted odds ratio was very similar, 1.45 (95 % CI: 1.14-1.84), when various sociodemographic and other risk factors were accounted for. The conditional average SBP and DBP levels were respectively 3.42 mmHg (95 % CI: 1.64-5.20) and 1.44 mmHg (95 % CI: 0.37-2.51) higher among minority women. Thus, we found evidence that religious minority women in Bangladesh had a disproportionately higher risk of having hypertension compared to their non-minority peers. These results call for further research on psychological distress from systematic discrimination and collective trauma among religious minorities in Bangladesh.

Role of life satisfaction, emotional support, and feeling of social isolation on adherence to breast cancer screening recommendations among US women.

BACKGROUND: Psychosocial factors can play important roles in promoting preventive health behaviors. This study aimed to assess how life satisfaction, receipt of emotional support, and feeling of social isolation were associated with adherence to the USPSTF recommendation of breast cancer screening in a nationally representative US population. METHODS: Using data on 71,583 women aged 50 to 74 years, from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated multivariable logistic regressions to assess the odds of adherence across different categories of the respective psychosocial constructs. We accounted for various demographic and socioeconomic correlates and checked the robustness of the relationship within income and educational sub-groups. RESULTS: We found that women who were dissatisfied with their life were 52.0% less likely to adhere compared to women who reported to be very satisfied. Similarly, women who rarely/never got emotional support and who always/usually felt socially isolated were 51.6% and 39.9% less likely to adhere, compared to women who always got support and never felt isolated, respectively. These results were robust across different levels of income and educational attainment. CONCLUSION: Our findings demonstrated a strong association between social environment, psychological wellbeing, and adherence to breast cancer screening, and thus suggested scope of potential psychosocial interventions to improve adherence. POLICY SUMMARY: Efforts to improve women's psychosocial wellbeing could facilitate compliance with breast cancer screening recommendations.

COVID-19 and health care-related financial toxicity in the United States: Evidence from the 2022 National Health Interview Survey.

BACKGROUND: Despite the common perception of the socioeconomic burden of the COVID-19 pandemic, quantification of the relationship between COVID-19 and indicators of health care-related financial toxicity in the general population has been limited. This study aimed to provide estimates of these relationships in a nationally representative sample of the US adult population. METHODS: Using the data on 27,480 adults from the 2022 National Health Interview Survey, we fitted multivariable logistic regression models to assess the differential risks of financial toxicity as manifested by the financial hardship in paying medical bills, delayed and forgone medical care, and medication nonadherence, by COVID-19 diagnosis, severity, and duration of symptoms. RESULTS: We found that compared to individuals not having COVID-19, individuals with severe symptoms of COVID-19 were 1.86, 1.50, 1.76, and 1.77 times more likely to experience financial hardship, delay medical care, forgo medical care, and skip/delay/take less medication, respectively. Similarly, individuals with symptoms lasting for 3 or more months were 1.94, 1.65, 1.87, and 2.20 times more likely to experience these measures of financial toxicity, respectively. CONCLUSIONS: The estimates of the relationship between COVID-19 and financial toxicity will facilitate effective communications for policy actions aimed at alleviating the burden of the COVID-19 pandemic.

Spousal age difference and risk of hypertension in women: evidence from India.

There has been steady progress in documenting the psychosocial risk factors of hypertension. However, most of the extant evidence is based on population from the developed countries. Using nationally representative data from India, this cross-sectional study explores whether spousal age gap is associated with risk of hypertension in married women aged 20 to 49 years. Based on the age difference with their husbands, women were grouped into four categories: husband was - i) of similar age, ii) 3-5 years older, iii) 6-9 years older, and iv) 10+ years older. Compared to women whose husbands were of similar age, the odds of having hypertension for the other categories were assessed by estimating multivariable logistic regression models. While the hypertension prevalence in our sample was 18.9%, it was 2.2%-points lower among women whose husbands were of similar age, and 3.3%-points higher among women whose husbands were 10+ years older. The adjusted odds of having hypertension for women with 10+ years of spousal age difference were 1.18 (95% CI: 1.13-1.24) times that of their counterparts who were of similar age to their husbands. These results were persistent in both younger (age 20-34) and older (age 35-49) women and robust across age at marriage, years in marriage, and various socioeconomic sub-groups including women's educational attainment, husband's educational level, household wealth, urban/rural residence, and geographic regions. The relationship also persisted after adjusting for husband's hypertension status. Our findings thus highlight spousal age difference as a biopsychosocial factor influencing the risk of hypertension in women.

Medical financial hardship in the Southern United States: the struggle continues across generations pre- and post- the Affordable Care Act.

INTRODUCTION: Medical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations - Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA). METHODS: This observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre-ACA (2011-2013), ii) post ACA (2015-2018), and iii) COVID-19 pandemic (2021-2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage. RESULTS: Adults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage. CONCLUSIONS: The problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage.