Modeling State Firearm Law Adoption Using Temporal Network Models.

Policy Points Promoting healthy public policies is a national priority, but state policy adoption is driven by a complex set of internal and external factors. This study employs new social network methods to identify underlying connections among states and to predict the likelihood of new firearm-related policy adoption given changes to this interstate network. This approach could be used to assess the likelihood that a given state will adopt a specific new firearm-related law and to identify points of influence that could either inhibit or promote wider diffusion of specific laws. CONTEXT: US states are largely responsible for the regulation of firearms within their borders. Each state has developed a different legal environment with regard to firearms based on different values and beliefs of citizens, legislators, governors, and other stakeholders. Predicting the types of firearm laws that states may adopt is therefore challenging. METHODS: We propose a parsimonious model for this complex process and provide credible predictions of state firearm laws by estimating the likelihood they will be passed in the future. We employ a temporal exponential-family random graph model to capture the bipartite state law-state network data over time, allowing for complex interdependencies and their temporal evolution. Using data on all state firearm laws over the period 1979-2020, we estimate these models' parameters while controlling for factors associated with firearm law adoption, including internal and external state characteristics. Predictions of future firearm law passage are then calculated based on a number of scenarios to assess the effects of a given type of firearm law being passed in the future by a given state. FINDINGS: Results show that a set of internal state factors are important predictors of firearm law adoption, but the actions of neighboring states may be just as important. Analysis of scenarios provide insights into the mechanics of how adoption of laws by specific states (or groups of states) may perturb the rest of the network structure and alter the likelihood that new laws would become more (or less) likely to continue to diffuse to other states. CONCLUSIONS: The methods used here outperform standard approaches for policy diffusion studies and afford predictions that are superior to those of an ensemble of machine learning tools. The proposed framework could have applications for the study of policy diffusion in other domains.

Effective primary care attenuates the association between frailty and hospital admission in old age: the ELSI-Brazil.

BACKGROUND: Frailty is a multidimensional syndrome leading to a higher hospitalization. However, few studies explicitly analyze whether measures of effective primary care modify the relationship between frailty and hospital admission. METHODS: This cross-sectional study included data from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a representative community-based study with older adults aged 50 years and over, conducted in 2019-2021. Self-reported hospital admission in the past 12 months was the outcome. Frailty included the 5 phenotypic criteria: weight loss, exhaustion, low physical activity, weakness, and slowness. The effective primary care index included 12 attributes indicators, continuously. Statistical analyzes comprised logistic regression. RESULTS: Among the 7,436 study participants, frailty (odds ratio [OR] 2.17; 95% confidence intervals [95% CI] 1.31-3.62) and effective primary care index (OR 1.10; 95% CI 1.03-1.16) were positively associated with higher hospitalization. Interaction revealed that while effective primary care was positively associated with hospitalization, this association was different among frail older adults (OR 0.80; 95% CI 0.65-0.99). After stratification by frailty status, positive association with hospitalization remained only among prefrail and nonfrail individuals. The predicted probability of hospitalization tended to decrease along with higher primary care index values among frail older adults and became similar to prefrail/nonfrail at the highest end of the scale. CONCLUSIONS: Effective primary care decreases the likelihood of hospital admission among frail older adults. Interventions for delaying frailty should be initiated in primary care along with policies to strengthen primary care's organizational and provider/team-level attributes.

Frailty is a multidimensional syndrome leading to a higher hospitalization. However, few studies explicitly analyze whether measures of effective primary care modify the relationship between frailty and hospital admission. Using data from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a representative community-based study with older adults aged 50 years and over, we evaluated self-reported hospital admission in the past 12 months, frailty according to 5 phenotypic criteria, and an effective primary care index with 12 attributes indicators. According to data of 7,436 study participants, we revealed that while effective primary care index was positively associated with hospital admission, this association was different among frail older adults. After stratification by frailty status, positive association with hospitalization remained only among prefrail and nonfrail individuals. Therefore, effective primary care decreases the likelihood of hospital admission among frail older adults. Interventions for delaying frailty should be initiated in primary care along with policies to strengthen primary care's organizational and provider/team-level attributes.

Healthcare utilization among older Brazilians during the COVID-19 pandemic: The Brazilian Longitudinal Study of Ageing-COVID-19 initiative.

BACKGROUND: As the COVID-19 pandemic progresses, understanding its sustained impact on healthcare access and utilization represents a vital task for decision-makers and health systems. This study investigates how three aspects of health care utilization (i.e., consultations for COVID-19 related symptoms, cancelation of previously scheduled care and hospitalisation in the past 30 days) relate to individual and municipal factors in a nationally-representative sample of Brazilians aged 50 and over. METHODS: Data were obtained for 6584 participants from the second wave of the Brazilian Longitudinal Study of Ageing (ELSI-Brazil in Portuguese) who were administered supplemental telephone interviews between September and October 2020. Descriptive statistics, bivariate analysis and multivariate analysis using survey-weighted Poisson regression were applied to evaluate all three outcomes of interest (consultation, care cancelation, and hospitalisation). Predicted probabilities were also calculated to understand the overall effect of relevant covariates. RESULTS: Women were 76% less likely to seek care for COVID-19 symptoms (Odds Ratio [OR] = 0.24, 95% Confidence Interval [CI] = 0.10, 0.53) and 82% more likely to have healthcare cancelled due to the pandemic (OR = 1.82, 95% CI = 1.43, 2.33) than men. Those who live in municipalities with low coverage (<40%) of community-based primary care (the Family Health Strategy) were more likely (OR = 1.80, 95% CI = 1.00, 3.22) to be hospitalised for any reason in the past 30 days and more likely to experience healthcare cancelation (OR = 1.43, 95% CI = 1.01, 2.02). Living in the Southeast and Midwest regions was associated with 62% and 78%, respectively, lower odds of previously scheduled care being cancelled due to the pandemic, in comparison to the North region (OR = 0.38, 95% CI = 0.21, 0.67, and OR = 0.22, 95% CI = 0.14, 0.36). Living in the Southeast region was associated with over 7.61 higher odds of having sought care for COVID-19-related symptoms, relative to those living in the North (OR = 7.61, 95% CI = 2.16, 26.85). CONCLUSION: Results highlight the uneven impact of the COVID-19 pandemic on health care utilization between males and females, and across Brazilian municipalities and regions.

Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil.

Objectives. To investigate the role of the Family Health Strategy (FHS) in reducing social inequalities in mortality over a 9-year follow-up period.Methods. We carried out a population-based cohort study of individuals aged 60 years and older from the city of Bagé, Brazil. Of 1593 participants at baseline (2008), 1314 (82.5%) were included in this 9-year follow-up (2017). We assessed type of primary health care (PHC) coverage and other variables at baseline. In 2017, we ascertained 579 deaths through mortality registers. Hazard ratios and their 95% confidence intervals modeled time to death estimated by Cox regression. We also tested the effect modification between PHC and wealth.Results. The FHS had a protective effect on mortality among individuals aged 60 to 64 years, a result not found among those not covered by the FHS. Interaction analysis showed that the FHS modified the effect of wealth on mortality. The FHS protected the poorest from all-cause mortality (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.36, 0.96) and avoidable mortality (HR = 0.46; 95% CI = 0.25, 0.85).Conclusions. FHS coverage reduced social inequalities in mortality among older adults. Our findings highlight the need to guarantee universal health coverage in Brazil by expanding and strengthening the FHS to promote health equity.

Maternal height and double-burden of malnutrition households in Mexico: stunted children with overweight or obese mothers.

OBJECTIVE: To assess the association between short maternal height and four types of mother-child nutritional status groupings within Mexican households. DESIGN: We classified mother-child dyads into four groups: stunted child and a non-overweight/non-obese mother (stunting-only), non-stunted child and an overweight/obese mother (overweight-only), stunted child with an overweight/obese mother (double-burden) and households with neither child stunting nor overweight/obese mothers (neither-condition). We assessed the association between maternal height and mother-child nutrition status using multinomial logistic regression, controlling for socio-economic covariates. SETTING: Nationally representative cross-section of households from the 2012 Mexican National Health and Nutrition Survey. PARTICIPANTS: Children <5 years of age were matched to their mothers, resulting in a sample of 4706 mother-child dyads. RESULTS: We found that among children with stunting, 53·3% have an overweight/obese mother. Double-burden was observed in 8·1% of Mexican households. Maternal short stature increased the probability of stunting-only by 3·5% points (p.p.) and double-burden by 9·7 p.p. (P < 0·05). The inverse association was observed for overweight-only and neither-condition households, where the probability of these outcomes decreased by 7·2 and 6 p.p. in households with short-statured mothers (P < 0·05), respectively. CONCLUSIONS: Women with short stature are more likely to develop overweight and simultaneously have a stunted child than those who are not short-statured. Our findings underline the challenges faced by public health systems, which have to balance the provision of services for both an undernourished and increasingly overweight/obese population.

Life-course risk factors are associated with activity of daily living disability in older adults.

BACKGROUND: Multiple risk factors accumulate over the life-course and contribute to higher rates of disability at older ages. This study investigates whether three life-course risk factors (low educational attainment, poor health in childhood and multimorbidity) are associated with increased risk of disability [defined as any limitation in basic activities of daily living (BADL)] in older adults and whether this relationship is moderated by the national socioeconomic context, measured by the Human Development Index (HDI). METHODS: Data include 100 062 adults (aged 50 and over) participating in longitudinal studies of aging conducted in 19 countries. Analyses include multivariable Poisson models with robust standard errors to assess the associations between HDI, life-course risk factors and other individual-level control variables (sex and age) with any BADL disability. RESULTS: In country-specific analyses, both educational attainment and multimorbidity are independently associated with disability in nearly every country. The interaction between these risk factors further increases the magnitude of this association. In pooled regression analyses, the relationship between life-course risk factors and disability is moderated by a country's HDI. For individuals with all three life-course risk factors, the predicted probability of disability ranged from 36.7% in the lowest HDI country to 21.8% in the highest HDI country. CONCLUSIONS: Social and health system policies directed toward reducing the development of life-course risk factors are essential to reduce disability in all countries, but are even more urgently needed in those with lower levels of socioeconomic development.

Brazil's unified health system: the first 30 years and prospects for the future.

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America.

BACKGROUND: While in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. METHODS: We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. RESULTS: Possible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. CONCLUSIONS: The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

Unavailability of paid sick leave among parents is a barrier for children's utilization of nonemergency health services: Evidence from the National Health Interview Survey.

OBJECTIVE: To assess the association between availability of paid sick leave among parents and children's use of several distinct types of nonurgent health services and emergency care. METHODS: Using pooled 2013 to 2017 data from the National Health Interview Survey (NHIS), we created dyadic units of observation linking adults with their children (n = 21 235). Descriptive statistics, logistic regressions for binary outcomes, and regular and zero-inflated negative binomial regressions for count outcomes assessed the relationship between parental coverage by paid sick leave benefits and 12 dependent variables related to health care utilization. Regression analyses controlled for a set of child, parent, and family covariates. RESULTS: Overall, 58.3% of individuals in our sample reported having paid sick leave in their current or latest job. There are substantial disparities in availability of paid sick leave in terms of parent sex, race, education, and income. Controlling for covariates, the odds of children with at least one parent with access to paid sick leave having any visit to a medical office in the past 12 months are 27% higher than for children whose parents do not have this benefit. Similar positive associations were observed for general doctor visit (OR = 1.18, 95%CI: 1.05-1.32), mental health professional visit (OR = 1.19, 95%CI: 1.01-1.42), and receipt of flu vaccination (OR = 1.21, 95%CI: 1.11-1.33). There was no statistically significant association with emergency room use, once covariates were controlled. CONCLUSIONS: Availability of paid sick leave among parents is associated with increased children's utilization of nonemergency health services and primary care.

Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Short relative leg length is associated with overweight and obesity in Mexican immigrant women.

BACKGROUND: Prior research suggests that undernutrition and enteric infections predispose children to stunted growth. Undernutrition and infections have been associated with limited access to healthy diets, lack of sanitation, and access barriers to healthcare - all associated with human rights. Stunting has also been documented to be a major determinant of subsequent obesity and non-communicable diseases. Short leg length relative to stature during adulthood seems to be a good proxy indicator tracking such barriers, and has been reported to be associated with adverse health effects during adulthood. Our objective was to examine the association between relative leg length (as measured by the leg length index, LLI) and measures of adiposity - based on body mass index (BMI) and waist circumference (WC) - in a population of recent Mexican immigrant women to the New York City Area. METHODS: The analysis was based on a cross-sectional survey of 200 Mexican immigrant women aged 18 to 70 years, whose data were collected between April and November 2008; although for purposes of the current study we restricted the sample to those aged 18 to 59 years. The dependent variables were BMI and WC, both transformed into categorical variables. The main independent variable was LLI, and other correlates were controlled for (i.e. age, education, having had children, characteristics of the community of origin, acculturation, chronic conditions, sedentary behaviors, access to fresh fruits and vegetables). Two probit models were estimated: the first one analyzed the effect of LLI on BMI categories and the second one estimated the effect of LLI on WC. RESULTS: The probit assessing the effect of LLI on overweight/obesity suggested that having a short LLI increased the probability of overweight/obesity by 21 percentage points. Results from the probit model estimating the effect of LLI on WC indicated that having a short LLI increased the probability of having abdominal adiposity by 39 percentage points. Both results were statistically significant at p < 0.05. CONCLUSION: The study found an association between having shorter legs relative to one's height and increased risk of overweight/obesity and abdominal adiposity. Findings support the epidemiological evidence regarding the association between short leg length, early life socioeconomic conditions (i.e. limited access to basic rights), and increased risk of adverse health effects later in life.

Presence of Counterfeit Marlboro Gold Packs in Licensed Retail Stores in New York City: Evidence From Test Purchases.

BACKGROUND: There are no independent studies measuring the availability of premium brand counterfeit cigarettes in New York City from licensed retailers. METHODS: We forensically analyzed the cigarette packaging of Marlboro Gold (n = 1021) purchased from licensed tobacco retailers in New York City, using ultraviolet irradiation and light microscopy to determine whether they were counterfeit. RESULTS: We find that while only 0.5% (n = 5) of our sample exhibits at least one characteristic synonymous with counterfeit packaging, none of our packs can be conclusively classified as counterfeit. CONCLUSIONS: We do not find any counterfeit Marlboro Gold packs purchased at full price from licensed cigarette retailers throughout New York City. Future research using test purchases should include other venues (eg, street and online) and specifically ask for discounts to ascertain the overall presence of counterfeit cigarettes. IMPLICATIONS: This is the first study to independently measure the availability of counterfeit cigarette packs purchased at full price from licensed retailers in New York City. We find that none of the Marlboro Gold packs purchased from licensed cigarette retailers are counterfeit.

The impact of the health care workforce on under-five mortality in rural China.

BACKGROUND: Previous studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period. METHODS: We estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources. RESULTS: The U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly. CONCLUSIONS: This study demonstrates that increased health professionals were associated with reductions in U5MR. The largest association was seen in poor counties and those with low and slowly increasing GDP per capita, which justifies further expansion of the health care workforce in these areas. This study could be instructive for other developing countries to achieve Sustainable Development Goal 3 by helping them identify where additional health professionals would make the greatest contribution.

Primary care and multimorbidity in six Latin American and Caribbean countries.

OBJECTIVES: To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. METHODS: Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. RESULTS: The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. CONCLUSIONS: Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

Impact of New York City's 2014 Increased Minimum Legal Purchase Age on Youth Tobacco Use.

OBJECTIVES: To assess the impact of New York City's (NYC's) 2014 increase of the minimum legal purchase age (MLPA) for tobacco and e-cigarettes from 18 to 21 years. METHODS: We performed a difference-in-differences analysis comparing NYC to the rest of New York State by using repeated cross-sections of the New York Youth Tobacco Survey (2008-2016) and to 4 Florida cities by using the Youth Risk Behavior Surveys (2007-2015). RESULTS: Adolescent tobacco use declined slightly in NYC after the policy change. However, this rate of change was even larger in control locations. In NYC, e-cigarette use increased and reported purchases of loose cigarettes remained unchanged, suggesting uneven policy implementation, enforcement, or compliance. CONCLUSIONS: Increasing the MLPA to 21 years in NYC did not accelerate reductions in youth tobacco use any more rapidly than declines observed in comparison sites. Public Health Implications. Other cities and states currently raising their MLPA for tobacco may need to pay close attention to policy enforcement and conduct enhanced monitoring of retailer compliance to achieve the full benefits of the policy.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Bullying involvement and substance use among Brazilian adolescent students.

OBJECTIVE: Although bullying involvement has been associated with adolescent substance use, most of this evidence comes from high-income countries. Little is known about substance use among perpetrator-victims in low- and middle-income countries. This study explores the association between types of bullying involvement and adolescent substance use in Brazil. METHODS: Data for this cross-sectional study came from the 2015 Pesquisa Nacional de Saúde do Escolar [National Adolescent School-based Health Survey] (PeNSE), a nationwide school-based survey of Brazilian ninth graders. Substance use was analyzed as any substance use (i.e., use of alcohol, cigarettes, or marijuana in the previous 30 days) and substance co-use (i.e., use of all three substances). Logistic regression analyses were conducted, and adjusted odds ratios (aORs) were calculated, adjusting for demographic characteristics and student loneliness. RESULTS: Odds of any substance use for bullying perpetrators-only and for perpetrator-victims, respectively, were significantly higher compared to no bullying involvement (aOR = 2.99, 95% CI = 2.71-3.30 and aOR = 2.52, 95% CI = 2.31-2.75). Adjusted odds of substance co-use were also significantly higher among perpetrators-only and perpetrator-victims (aOR = 4.04, 95% CI = 3.05-5.35 and aOR = 3.49, 95% CI = 2.71-4.51, respectively). Victimization-only was associated with a 14% increase in the odds of any substance use (aOR = 1.14, 95% CI = 1.07-1.22). CONCLUSIONS: The results underscore the complex relationship between adolescent bullying involvement and substance use. Findings also indicate the type of bullying involvement, as well as demographic and psychological factors, should be taken into consideration when assessing adolescent health-risk behaviors.

Measuring the bias against low-income country research: an Implicit Association Test.

BACKGROUND: With an increasing array of innovations and research emerging from low-income countries there is a growing recognition that even high-income countries could learn from these contexts. It is well known that the source of a product influences perception of that product, but little research has examined whether this applies also in evidence-based medicine and decision-making. In order to examine likely barriers to learning from low-income countries, this study uses established methods in cognitive psychology to explore whether healthcare professionals and researchers implicitly associate good research with rich countries more so than with poor countries. METHODS: Computer-based Implicit Association Test (IAT) distributed to healthcare professionals and researchers. Stimuli representing Rich Countries were chosen from OECD members in the top ten (>$36,000 per capita) World Bank rankings and Poor Countries were chosen from the bottom thirty (<$1000 per capita) countries by GDP per capita, in both cases giving attention to regional representation. Stimuli representing Research were descriptors of the motivation (objective/biased), value (useful/worthless), clarity (precise/vague), process (transparent/dishonest), and trustworthiness (credible/unreliable) of research. IAT results are presented as a Cohen's d statistic. Quantile regression was used to assess the contribution of covariates (e.g. age, sex, country of origin) to different values of IAT responses that correspond to different levels of implicit bias. Poisson regression was used to model dichotomized responses to the explicit bias item. RESULTS: Three hundred twenty one tests were completed in a four-week period between March and April 2015. The mean Implicit Association Test result (a standardized mean relative latency between congruent and non-congruent categories) for the sample was 0.57 (95% CI 0.52 to 0.61) indicating that on average our sample exhibited moderately strong implicit associations between Rich Countries and Good Research. People over 40 years of age were less likely to exhibit pro-poor implicit associations, and being a peer reviewer contributes to a more pro-poor association. CONCLUSIONS: The majority of our participants associate Good Research with Rich Countries, compared to Poor Countries. Implicit associations such as these might disfavor research from poor countries in research evaluation, evidence-based medicine and diffusion of innovations.

Changes in health care inequity in Brazil between 2008 and 2013.

BACKGROUND: Brazil has made progress towards a more equitable distribution of health care, but gains may be threatened by economic instability resulting from the 2008 global financial crisis. This study measured predictors of health care utilization and changes in horizontal inequity between 2008 and 2013. METHOD: Data were from two nationally representative surveys that measured a variety of sociodemographic, health behaviors and health care indicators. We used Poisson regression models to estimate adjusted prevalence ratios and the Horizontal Equity Index (HEI) standardized by health needs to measure inequity in the utilization of doctor and dentist visits, hospitalizations and reporting of a usual source of care (USC) for those 18 and older. To estimate the HEI, we ranked the population from the poorest to the richest using a wealth index. We also decomposed the HEI into its different components and assessed changes from 2008 to 2013. RESULTS: The population proportion with doctor and dentist visits in the past year and a USC increased between 2008 and 2013, while hospitalizations declined. In 2013, pro-rich inequity in doctor visits increased significantly while the distribution of hospitalizations shifted from pro-rich in 2008 to neutral in 2013. Dentist visits were highly pro-rich and USC was slightly pro-rich; the distribution of dentist visits and USC did not change over time. Health need was a strong predictor of health care utilization regardless of the type of coverage (public or private). Education, wealth, and private health plans were associated with the pro-rich orientation of doctor and dentist visits. Private health plans contributed to the pro-rich orientation of all outcomes, while the Family Health Strategy contributed to the pro-poor orientation of all outcomes. CONCLUSION: The results of this study support the claim that Brazil's population continued to see absolute gains in access to care despite recent economic crises. However, gains in equity have slowed and may even decline if investments are not maintained as the country enters deeper financial and political crises.

Socioeconomic inequalities in activities of daily living limitations and in the provision of informal and formal care for noninstitutionalized older Brazilians: National Health Survey, 2013.

BACKGROUND: This study assesses the association between socioeconomic factors and living arrangements with activity of daily living limitations (ADL) and the receipt of informal and formal care among non-institutionalized Brazilians aged ≥ 60 years. METHODS: Data come from a nationally representative survey (the Brazilian National Health Survey), conducted in 2013. Outcomes examined include the number of ADL tasks performed with limitations and number of tasks for which the individual received informal care (provided by unpaid relatives or friends), formal care, or no care. Key exposure variables were years of education and household assets. RESULTS: Functioning limitations were reported by 7,233 (30.1 %) of 23,815 survey participants. Of these, 5,978 reported needing help to perform at least one ADL task. There was a strong inverse gradient between physical functioning and both education and household assets that was independent of confounders. The provision of care showed an opposite trend, with the wealthiest being more likely to receive help for performing ADL tasks. The receipt of formal care was strongly correlated with highest education (Fully adjusted prevalence ratio [PR] = 1.64; 95 % CI 1.05, 2.58) and with the highest assets level (PR = 2.24; 95 % CI 1.38, 3.64). Living with someone else was associated with provision of care (formal or informal) for those at the lowest and intermediate educational and assets levels, but not for the wealthiest. CONCLUSION: Despite worse physical functioning, older Brazilians in worse socioeconomic conditions are much less likely to receive needed help in performing ADL tasks.