U.S. state policy contexts and mortality of working-age adults.

The rise in working-age mortality rates in the United States in recent decades largely reflects stalled declines in cardiovascular disease (CVD) mortality alongside rising mortality from alcohol-induced causes, suicide, and drug poisoning; and it has been especially severe in some U.S. states. Building on recent work, this study examined whether U.S. state policy contexts may be a central explanation. We modeled the associations between working-age mortality rates and state policies during 1999 to 2019. We used annual data from the 1999-2019 National Vital Statistics System to calculate state-level age-adjusted mortality rates for deaths from all causes and from CVD, alcohol-induced causes, suicide, and drug poisoning among adults ages 25-64 years. We merged that data with annual state-level data on eight policy domains, such as labor and taxes, where each domain was scored on a 0-1 conservative-to-liberal continuum. Results show that the policy domains were associated with working-age mortality. More conservative marijuana policies and more liberal policies on the environment, gun safety, labor, economic taxes, and tobacco taxes in a state were associated with lower mortality in that state. Especially strong associations were observed between certain domains and specific causes of death: between the gun safety domain and suicide mortality among men, between the labor domain and alcohol-induced mortality, and between both the economic tax and tobacco tax domains and CVD mortality. Simulations indicate that changing all policy domains in all states to a fully liberal orientation might have saved 171,030 lives in 2019, while changing them to a fully conservative orientation might have cost 217,635 lives.

Workplace hazards and health among informally employed domestic workers in 14 cities, United States, 2011-2012: Using four approaches to characterize workers' patterns of exposures.

BACKGROUND: We characterized informally employed US domestic workers' (DWers) exposure to patterns of workplace hazards, as well as to single hazards, and examined associations with DWers' work-related and general health. METHODS: We analyzed cross-sectional data from the sole nationwide survey of informally employed US DWers with work-related hazards data, conducted in 14 cities (2011-2012; N = 2086). We characterized DWers' exposures using four approaches: single exposures (n = 19 hazards), composite exposure to hazards selected a priori, classification trees, and latent class analysis. We used city fixed effects regression to estimate the risk ratio (RR) of work-related back injury, work-related illness, and fair-to-poor self-rated health associated with exposure as defined by each approach. RESULTS: Across all four approaches-net of individual, household, and occupational characteristics, and city fixed effects-exposure to workplace hazards was associated with increased risk of the three health outcomes. For work-related back injury, the estimated RR associated with heavy lifting (the single hazard with the largest RR), exposure to all three hazards selected a priori (worker did heavy lifting, climbed to clean, and worked long hours) versus none, exposure to the two hazards identified by classification trees (heavy lifting, verbally abused) versus "no heavy lifting," and membership in the most- versus least-exposed latent class were, respectively, 3.4 (95% confidence interval [CI] 2.7-4.1); 6.5 (95% CI 4.8-8.7); 4.4 (95% CI 3.6-5.3), and 6.6 (95% CI 4.6-9.4). CONCLUSIONS: Measures of joint work-related exposures were more strongly associated than single exposures with informally employed US DWers' health profiles.

A Novel Use of Latent Class Analysis to Identify Patterns of Workplace Hazards among Informally Employed Domestic Workers in 14 Cities, United States, 2011-2012.

INTRODUCTION: Few studies, mostly descriptive, have quantitatively analyzed the working conditions of domestic workers (DWers) informally employed by private households in the USA. These workers are explicitly or effectively excluded from numerous workplace protections, and scant data exist on their exposures or how best to categorize them. METHODS: We analyzed data from the sole nationwide survey of informally employed US DWers with work-related hazards data, conducted by the National Domestic Workers Alliance, the University of Illinois Chicago Center for Urban Economic Development, and the DataCenter in 14 US cities (2011-2012; N = 2086). We used exploratory latent class analysis to identify groups of DWers with distinct patterns of exposure to 21 self-reported economic, social, and occupational workplace hazards (e.g. pay violations, verbal abuse, heavy lifting). We then used multinomial logistic latent class regression to examine associations between workers' individual, household, and occupational characteristics and latent class membership. RESULTS: Among the 2086 DWers, mean age was 42.6 years, 97.3% were women, 56.0% Latina/o, 26.5% White, 33.2% undocumented immigrants, and 11.7% live-in. 53.5%, 32.0%, and 14.5% primarily worked doing housecleaning, child care, and adult care, respectively. 49.9% of workers reported ≥3 hazards. Latent class analysis identified four groups of DWers doing: 'Low hazard domestic work' (lowest exposure to all hazards), 'Demanding care work' (moderate exposure to pay violations [item response probability (IRP) = 0.42] and contagious illness care [IRP = 0.39]), 'Strenuous cleaning work' (high exposure to cleaning-related occupational hazards, such as climbing to clean [IRP = 0.87]), and 'Hazardous domestic work' (highest exposure to all but one hazard). Covariates were strongly associated, in many cases, with latent class membership. For example, compared to other DWers, DWers doing 'hazardous domestic work' had the largest predicted probability of being economically insecure (0.53) and living-in with their employers (0.17). CONCLUSIONS: Results indicate that informally employed US DWers experience distinct patterns of workplace hazards, and that it is informative to characterize DWers' exposures to different sets of multiple hazards using latent class analysis.

Inequality in Place: Effects of Exposure to Neighborhood-Level Economic Inequality on Mortality.

This study contributes to the debate on whether income inequality is harmful for health by addressing several analytical weaknesses of previous studies. Using the Panel Study of Income Dynamics in combination with tract-level measures of income inequality in the United States, we estimate the effects of differential exposure to income inequality during three decades of the life course on mortality. Our study is among the first to consider the implications of income inequality within U.S. tracts for mortality using longitudinal and individual-level data. In addition, we improve upon prior work by accounting for the dynamic relationship between local areas and individuals' health, using marginal structural models to account for changes in exposure to local income inequality. In contrast to other studies that found no significant relation between income inequality and mortality, we find that recent exposure to higher local inequality predicts higher relative risk of mortality among individuals at ages 45 or older.

New Measures of Economic Insecurity Reveal its Expansion Into EU Middle Classes and Welfare States.

Economic instability, social changes, and new social policies place economic insecurity high on the scholarly and political agenda. We contribute to these debates by proposing a new multidimensional, intertemporal measure of economic insecurity that accounts for both its multiplicity and its dynamism. First, we develop three theory-driven, multidimensional measures of economic insecurity. Principal Components Analysis validates the measure. Second, we develop a dynamic approach to insecurity, using longitudinal data and a newly revised headcount method. Third, we then use our new measures to analyze the distribution of insecurity in Europe. Our analysis shows that insecurity is widespread across Europe, even in low-inequality, encompassing welfare states. Moreover, it extends across income groups and occupational classes, reaching into the middle classes.

"Registries are not only a tool for data collection, they are for action": Cancer registration and gaps in data for health equity in six population-based registries in India.

In India, population-based cancer registries (PBCRs) cover less than 15% of the urban and 1% of the rural population. Our study examines practices of registration in PBCRs in India to understand efforts to include rural populations in registries and efforts to measure social inequalities in cancer incidence. We selected a purposive sample of six PBCRs in Maharashtra, Kerala, Punjab and Mizoram and conducted semistructured interviews with staff to understand approaches and challenges to cancer registration, and the sociodemographic information collected by PBCRs. We also conducted a review of peer-reviewed literature utilizing data from PBCRs in India. Findings show that in a context of poor access to cancer diagnosis and treatment and weak death registration, PBCRs have developed additional approaches to cancer registration, including conducting village and home visits to interview cancer patients in rural areas. Challenges included PBCR funding and staff retention, abstraction of data in medical records, address verification and responding to cancer stigma and patient migration. Most PBCRs published estimates of cancer outcomes disaggregated by age, sex and geography. Data on education, marital status, mother tongue and religion were collected, but rarely reported. Two PBCRs collected information on income and occupation and none collected information on caste. Most peer-reviewed studies using PBCR data did not publish estimates of social inequalities in cancer outcomes. Results indicate that collecting and reporting sociodemographic data collected by PBCRs is feasible. Improved PBCR coverage and data will enable India's cancer prevention and control programs to be guided by data on cancer inequities.

US State Policies, Politics, and Life Expectancy.

Policy Points Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy. Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries. CONTEXT: Life expectancy in the United States has increased little in previous decades, declined in recent years, and become more unequal across US states. Those trends were accompanied by substantial changes in the US policy environment, particularly at the state level. State policies affect nearly every aspect of people's lives, including economic well-being, social relationships, education, housing, lifestyles, and access to medical care. This study examines the extent to which the state policy environment may have contributed to the troubling trends in US life expectancy. METHODS: We merged annual data on life expectancy for US states from 1970 to 2014 with annual data on 18 state-level policy domains such as tobacco, environment, tax, and labor. Using the 45 years of data and controlling for differences in the characteristics of states and their populations, we modeled the association between state policies and life expectancy, and assessed how changes in those policies may have contributed to trends in US life expectancy from 1970 through 2014. FINDINGS: Results show that changes in life expectancy during 1970-2014 were associated with changes in state policies on a conservative-liberal continuum, where more liberal policies expand economic regulations and protect marginalized groups. States that implemented more conservative policies were more likely to experience a reduction in life expectancy. We estimated that the shallow upward trend in US life expectancy from 2010 to 2014 would have been 25% steeper for women and 13% steeper for men had state policies not changed as they did. We also estimated that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies. CONCLUSIONS: Understanding and reversing the troubling trends and growing inequalities in US life expectancy requires attention to US state policy contexts, their dynamic changes in recent decades, and the forces behind those changes. Changes in US political and policy contexts since the 1970s may undergird the deterioration of Americans' health and longevity.

Analyzing and improving national and local child protection data in Nepal: A mixed methods study using 2014 Multiple Indicator Cluster Survey (MICS) data and interviews with 18 organizations.

BACKGROUND: Globally, progress to improve data on child protection outcomes has been slower than efforts to improve data on child nutrition, vaccination and development outcomes in the under-five age group. The Sustainable Development Goals included several child protection targets further necessitating the need to track progress on child protection, but few studies have examined the varied data landscape for child protection within countries. OBJECTIVE: This mixed-methods study aims to examine (1) the prevalence of child protection outcomes in Nepal, (2) the types of data the child protection sector uses, and (3) recommendations to improve the collection, analysis and use of child protection data. PARTICIPANTS AND SETTING: We used: (a) secondary data from the nationally-representative 2014 Nepal MICS which surveyed over 13,000 households to measure the national prevalence of child labor, child marriage, and violent discipline, and (b) primary data from 18 qualitative key informant interviews with organizations in Nepal's child protection sector. METHODS: We conducted descriptive quantitative analyses of the secondary data and thematic inductive and deductive qualitative analyses of transcripts of key informant interviews. RESULTS: The burden of violent discipline (82%), child labor (37%), child marriage (12%), and their co-occurrence is high in Nepal. Respondents described using a range of data sources which included: large-scale surveys, case data from the police, court system, newspapers, community consultations, and child participation. Recommendations to improve data included developing a national child protection information system, ensuring the definitions of child protection outcomes were comparable across data sources, and improving the dissemination of data.

Who benefits from social investment? The gendered effects of family and employment policies on cardiovascular disease in Europe.

BACKGROUND: In the context of fiscal austerity in many European welfare states, policy innovation often takes the form of 'social investment', a contested set of policies aimed at strengthening labour markets. Social investment policies include employment subsidies, skills training and job-finding services, early childhood education and childcare and parental leave. Given that such policies can influence gender equity in the labour market, we analysed the possible effects of such policies on gender health equity. METHODS: Using age-stratified and sex-stratified data from the Global Burden of Disease Study on cardiovascular disease (CVD) morbidity and mortality between 2005 and 2010, we estimated linear regression models of policy indicators on employment supports, childcare and parental leave with country fixed effects. FINDINGS: We found mixed effects of social investment for men versus women. Whereas government spending on early childhood education and childcare was associated with lower CVD mortality rates for both men and women equally, government spending on paid parental leave was more strongly associated with lower CVD mortality rates for women. Additionally, government spending on public employment services was associated with lower CVD mortality rates for men but was not significant for women, while government spending on employment training was associated with lower CVD mortality rates for women but was not significant for men. CONCLUSIONS: Social investment policies were negatively associated with CVD mortality, but the ameliorative effects of specific policies were gendered. We discuss the implications of these results for the European social investment policy turn and for future research on gender health equity.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

Are inequities decreasing? Birth registration for children under five in low-income and middle-income countries, 1999-2016.

INTRODUCTION: Although global birth registration coverage has improved from 58% to 71% among children under five globally, inequities in birth registration coverage by wealth, urban/rural location, maternal education and access to a health facility persist. Few studies examine whether inequities in birth registration in low-income and middle-income countries have changed over time. METHODS: We combined information on caregiver reported birth registration of 1.6 million children in 173 publicly available, nationally representative Demographic Health Surveys and Multiple Indicator Cluster Surveys across 67 low-income and middle-income countries between 1999 and 2016. For each survey, we calculated point estimates and 95% CIs for the percentage of children under 5 years without birth registration on average and stratified by sex, urban/rural location and wealth. For each sociodemographic variable, we estimated absolute measures of inequality. We then examined changes in non-registration and inequities between surveys, and annually. RESULTS: 14 out of 67 countries had achieved complete birth registration. Among the remaining 53 countries, 39 countries successfully decreased the percentage of children without birth registration. However, this reduction occurred alongside statistically significant increases in wealth inequities in 9 countries and statistically significant decreases in 10 countries. At the most recent survey, the percentage of children without birth registration was greater than 50% in 16 out of 67 countries. CONCLUSION: Although birth registration improved on average, progress in reducing wealth inequities has been limited. Findings highlight the importance of monitoring changes in inequities to improve birth registration, to monitor Sustainable Development Goal 16.9 and to strengthen Civil Registration and Vital Statistics systems.

Understanding the micro and macro politics of health: Inequalities, intersectionality & institutions - A research agenda.

This essay brings together intersectionality and institutional approaches to health inequalities, suggesting an integrative analytical framework that accounts for the complexity of the intertwined influence of both individual social positioning and institutional stratification on health. This essay therefore advances the emerging scholarship on the relevance of intersectionality to health inequalities research. We argue that intersectionality provides a strong analytical tool for an integrated understanding of health inequalities beyond the purely socioeconomic by addressing the multiple layers of privilege and disadvantage, including race, migration and ethnicity, gender and sexuality. We further demonstrate how integrating intersectionality with institutional approaches allows for the study of institutions as heterogeneous entities that impact on the production of social privilege and disadvantage beyond just socioeconomic (re)distribution. This leads to an understanding of the interaction of the macro and the micro facets of the politics of health. Finally, we set out a research agenda considering the interplay/intersections between individuals and institutions and involving a series of methodological implications for research - arguing that quantitative designs can incorporate an intersectional institutional approach.

Institutions, Incorporation, and Inequality: The Case of Minority Health Inequalities in Europe.

Scholars interested in the relationship between social context and health have recently turned attention further "upstream" to understand how political, social, and economic institutions shape the distribution of life chances across contexts. We compare minority health inequalities across 22 European countries ( N = 199,981) to investigate how two such arrangements-welfare state effort and immigrant incorporation policies-influence the distribution of health and health inequalities. We examine two measures of health from seven waves of the European Social Survey. Results from a series of multilevel mixed-effects models show that minority health inequalities vary across contexts and persist after accounting for socioeconomic differences. Cross-level interaction results show that welfare state effort is associated with better health for all groups but is unrelated to levels of inequality between groups. In contrast, policies aimed at protecting minorities from discrimination correlate with smaller relative health inequalities.

How social policy contributes to the distribution of population health: the case of gender health equity.

AIMS: In this study we aimed to analyze gender health equity as a case of how social policy contributes to population health. We analyzed three sets of social-investment policies implemented in Europe and previously hypothesized to reduce gender inequity in labor market outcomes: childcare; active labor market programs; and long-term care. METHODS: We use 12 indicators of social-investment policies from the OECD Social Expenditure Database, the OECD Family Database, and the Social Policy Indicators' Parental Leave Benefit Dataset. We draw outcome data from the 2015 Global Burden of Disease for years lived with disability and all-cause mortality among men and women ages 25-54 for 18 European nations over the 1995-2010 period. We estimate 12 linear regression models each for mortality and morbidity (i.e. years lived with disability), one per social-investment indicator. All models use country fixed-effects and cluster-robust standard errors. RESULTS: For years lived with disability, women benefit more from social investment for most indicators. The only exception is the percentage of young children in publicly funded childcare or schooling, which equally benefits men. For all-cause mortality, men benefit more or equally from social investment for most indicators, while women benefit more from government spending on direct job creation through civil employment. CONCLUSIONS: Social policy contributes to the distribution of population health. Social-investment advocates argue such policies in particular enhance economic gender equity. Our results show that these polices have ambiguous effects on gender health equity and even differential improvements among men for some outcomes.

Trading Equality for Health? Evaluating the Trade-off and Institutional Hypotheses on Health Inequalities in the Global South.

It has been suggested that as medicine advances and mortality declines, socioeconomic disparities in health outcomes will grow. Yet, most research on this topic uses data from affluent Western democracies, where mortality is declining in small increments. We argue that the Global South represents the ideal setting to study this issue in a context of rapid mortality decline. We evaluate two competing hypotheses: (1) there is a trade-off between population health and health inequality such that reductions in under-five mortality are linked to higher levels of social inequality in health; and (2) institutional interventions that improve under-five mortality, like the expansion of educational systems and public health expenditure, are associated with reductions in inequalities. We test these hypotheses using data on 1,369,050 births in 34 low-income countries in the Demographic and Health Surveys from 1995 to 2012. The results show little evidence of a health-for-equality trade-off and instead support the institutional hypothesis.

The Institutional Foundations of Medicalization: A Cross-national Analysis of Mental Health and Unemployment.

In this study, we question (1) whether the relationship between unemployment and mental healthcare use, controlling for mental health status, varies across European countries and (2) whether these differences are patterned by a combination of unemployment and healthcare generosity. We hypothesize that medicalization of unemployment is stronger in countries where a low level of unemployment generosity is combined with a high level of healthcare generosity. A subsample of 36,306 working-age respondents from rounds 64.4 (2005-2006) and 73.2 (2010) of the cross-national survey Eurobarometer was used. Country-specific logistic regression and multilevel analyses, controlling for public disability spending, changes in government spending, economic capacity, and unemployment rate, were performed. We find that unemployment is medicalized, at least to some degree, in the majority of the 24 nations surveyed. Moreover, the medicalization of unemployment varies substantially across countries, corresponding to the combination of the level of unemployment and of healthcare generosity.