Assessing the Level of Poverty and Utilization of Government Social Programs Among Tobacco Farmers in Indonesia.

INTRODUCTION: Studies examining profit suggest that former tobacco farmers do as well or better than current tobacco farmers. Research has yet to examine the relationship among current and former tobacco farmers, poverty, and receipt of government social assistance. This type of research is critical to understanding the direct and indirect subsidization of tobacco growing. This study analyzed tobacco farmers' poverty levels and receipt of government social assistance programs. AIMS AND METHODS: We designed and conducted an original four-wave economic survey of current and former tobacco farming households in Indonesia between 2016 and 2022. We then used descriptive analysis and probit regression for panel data to estimate the relationship between tobacco farming and poverty status. RESULTS: Tobacco farmers' per capita income and poverty rates vary across years. The poverty rate was significantly higher in the year with a higher-than-normal rainfall as it negatively affected farming outcomes. During this year, the poverty rate among current tobacco farmers was also higher than that of former tobacco farmers. Regression estimates from the panel data confirm the association between tobacco farming and the likelihood of being poor. We also found a high share of current tobacco farmers who receive government social assistance programs, such as cash transfer programs and a universal healthcare program. CONCLUSIONS: Our findings show high poverty rates-particularly during bad farming years-and high rates of government social assistance among tobacco farmers. The high rates of government assistance among tobacco farmers living in poverty show that the government is indirectly subsidizing the tobacco industry.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers.

BACKGROUND: Public assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan. METHODS: This retrospective cohort study included public assistance recipients from two municipalities. We obtained participants' sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants' unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants' age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined. RESULTS: We identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00-2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00-3.59) and with children (IR 2.35, 95% CI 1.11-4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41-1.35) and those living with children (IR 0.50, 95% CI 0.20-1.23). A higher frequency in asthma visits was observed among working recipients living with family. CONCLUSIONS: Working adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050.

BACKGROUND: Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. METHODS: We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. FINDINGS: Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. INTERPRETATION: Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. FUNDING: Bill & Melinda Gates Foundation.

Population Health Impact and Cost-Effectiveness of Community-Supported Agriculture Among Low-Income US Adults: A Microsimulation Analysis.

Objectives. To estimate the population-level effectiveness and cost-effectiveness of a subsidized community-supported agriculture (CSA) intervention in the United States.Methods. In 2019, we developed a microsimulation model from nationally representative demographic, biomedical, and dietary data (National Health and Nutrition Examination Survey, 2013-2016) and a community-based randomized trial (conducted in Massachusetts from 2017 to 2018). We modeled 2 interventions: unconditional cash transfer ($300/year) and subsidized CSA ($300/year subsidy).Results. The total discounted disability-adjusted life years (DALYs) accumulated over the life course to cardiovascular disease and diabetes complications would be reduced from 24 797 per 10 000 people (95% confidence interval [CI] = 24 584, 25 001) at baseline to 23 463 per 10 000 (95% CI = 23 241, 23 666) under the cash intervention and 22 304 per 10 000 (95% CI = 22 084, 22 510) under the CSA intervention. From a societal perspective and over a life-course time horizon, the interventions had negative incremental cost-effectiveness ratios, implying cost savings to society of -$191 100 per DALY averted (95% CI = -$191 767, -$188 919) for the cash intervention and -$93 182 per DALY averted (95% CI = -$93 707, -$92 503) for the CSA intervention.Conclusions. Both the cash transfer and subsidized CSA may be important public health interventions for low-income persons in the United States.

Housing Subsidies and Housing Stability are Associated with Better HIV Medical Outcomes Among Persons Who Experienced Homelessness and Live with HIV and Mental Illness or Substance Use Disorder.

Among 958 applicants to a supportive housing program for low-income persons living with HIV (PLWH) and mental illness or a substance use disorder, we assessed impacts of housing placement on housing stability, HIV care engagement, and viral suppression. Surveillance and administrative datasets provided medical and residence information, including stable (e.g., rental assistance, supportive housing) and unstable (e.g., emergency shelter) government-subsidized housing. Sequence analysis identified a "quick stable housing" pattern for 67% of persons placed by this program within 2 years, vs. 28% of unplaced. Compared with unplaced persons not achieving stable housing quickly, persons quickly achieving stable housing were more likely to engage in care, whether placed (per Poisson regression, ARR: 1.14;95% CI 1.09-1.20) or unplaced (1.19;1.13-1.25) by this program, and to be virally suppressed, whether placed (1.22;1.03-1.44) or unplaced (1.26, 1.03-1.56) by this program. Housing programs can help homeless PLWH secure stable housing quickly, manage their infection, and prevent transmission.

RESUMEN: Unas 958 personas de bajos recursos y quienes viven con VIH y enfermedades mentales o bien presentan problemas de abuso de sustancias solicitaron a un programa de vivienda complementada con servicios de apoyo. Entre ellas, se evaluó los impactos de la colocación en viviendas sobre la estabilidad en la misma, así como la participación en los cuidados médicos para el VIH, y la supresión de la carga viral. Las bases de datos administrativas y del registro de vigilancia brindaron información médica y domiciliar, incluyendo información sobre vivienda estable (por ejemplo, asistencia de pago de renta a largo plazo, o vivienda complementada con servicios de apoyo) y vivienda inestable (por ejemplo, alojamiento de emergencia temporal) subsidiada por el gobierno. El método "análisis de secuencia" permitió identificar una pauta caracterizada por estabilidad domiciliar conseguida de modo ligero (es decir, de forma oportuna) en el 67% de las personas quienes fueron colocadas por este programa dentro de un lapso de dos años, comparado con 28% de las personas quienes no fueron colocadas. En comparación con las personas quienes no fueron colocadas y no lograron estabilidad de vivienda de modo ligero, las personas quienes lograron estabilidad de vivienda de modo ligero tuvieron una mayor probabilidad de participar en cuidados médicos, ya sea que fueran colocadas (según regresión de Poisson, cociente de riesgo ajustado: 1.14; intervalo de confianza de 95%: 1.09-1.20) o no fueran colocadas (1.19, 1.13-1.25) por este programa, así como de lograr la supresión de la carga viral, ya sea que fueran colocadas (1.22, 1.03-1.44) o no fueran colocadas (1.26, 1.03-1.56) por este programa. Los programas que facilitan la colocación en o el pago de vivienda y apoyo en el mismo pueden ayudar a las personas con VIH y sin hogar obtener vivienda estable de modo ligero, controlar su infección, y prevenir la transmisión.

Geographic Targeting and Normative Frames: Revisiting the Equity of Conditional Cash Transfer Program Distribution in Bolivia, Colombia, Ecuador, and Peru.

BACKGROUND: Four Andean countries of Bolivia, Colombia, Ecuador, and Peru introduced national health-focused conditional cash transfer (CCT) programs in the 2000s. This study probes whether policymakers in these countries targeted CCT programs to subregions with the highest prevalence of ill-health or those with the lowest socioeconomic status (SES) to evaluate the equity of geographic targeting and means-testing, as well as the potential role of normative frames, bounded rationality, and clientelism as explanatory mechanisms for inequities in social spending. METHODS: The distribution of vaccination coverage, underweight, stunting, and child deaths is established both within and between subnational regions and SES quintiles from 1998 to 2012 using every available nationally representative household survey. The equity of CCT program targeting and strength of association with subregional SES and health outcomes are measured using generalized entropy index decomposition and meta-regression. Finally, simple predictive models for CCT targeting are created using lagged subregional SES, health outcomes, and concentration indices. RESULTS: Bolivia and Peru both effectively targeted at-risk subregions, but subregions in Peru with no CCT program coverage result in higher mistargeting rates for the country as a whole. Only Bolivia failed to attain CCT coverage concentration indices that are at least as large as the health inequalities they are targeting. Despite this insufficient progressivity, Bolivia has the most efficient subregional targeting, while the lowest rates of mistargeting for child deaths are found in Colombia and Ecuador. Finally, the simple predictive model performs as well or better than observed CCT coverage distribution for every country, year, and outcome. CONCLUSIONS: Both Peru and Ecuador have targeted programs to their poorest populations effectively, demonstrating that this is possible with both universal and geographic targeting. No clear evidence of clientelism was found, while the dominant normative frame underlying CCT program targeting decisions appears to be the relative SES of subregions, rather than absolute SES, prevalence of health outcomes, or health inequalities. To reduce the inequitable impacts of bounded rationality, policymakers can use simple predictive models to target CCT coverage effectively and without leaving behind the most vulnerable populations that happen to live in more affluent subregions.

Understanding equity of institutional delivery in public health centre by level of care in India: an assessment using benefit incidence analysis.

BACKGROUND: The National Health Mission (NHM), the largest ever publicly funded health programme worldwide, used over half of the national health budget in India and primarily aimed to improve maternal and child health in the country. Though large scale public health investment has improved the health care utilization and health outcomes across states and socio-economic groups in India, little is known on the equity concern of NHM. In this context, this paper examines the utilization pattern and net benefit of public subsidy for institutional delivery by the level of care in India. METHODS: Data from the most recent round of the National Family Health Survey (NFHS 4), conducted during 2015-16, was used in the study. A total of 148,645 last birth delivered in a health centre during the 5 years preceding the survey were used for the analyses. Out-of-pocket (OOP) payment on delivery care was taken as the dependent variable and was analysed by primary care and secondary level of care. Benefits Incidence Analysis (BIA), descriptive statistics, concentration index (CI), and concentration curve (CC) were used to do the analysis. RESULTS: Institutional delivery from the public health centres in India is pro-poor and has a strong economic gradient. However, about 28% mothers from richest wealth quintile did not pay for delivery in public health centres compared to 16% among the poorest wealth quintile. Benefit incidence analyses suggests a pro-poor distribution of institutional delivery both at primary and secondary level of care. In 2015-16, at the primary level, about 32.29% of subsidies were used by the poorest, 27.22% by poorer, 20.39% by middle, 13.36% by richer and 6.73% by the richest wealth quintile. The pattern at the secondary level was similar, though the magnitude was lower. The concentration index of institutional delivery in public health centres was - 0.161 [95% CI, - 0.158, - 0.165] compared to 0.296 [95% CI, 0.289, 0.303] from private health centres. CONCLUSION: Provision and use of public subsidy for institutional delivery in public health centres is pro-poor in India. Improving the quality of service in primary health centres is recommended to increase utilisation and reduce OOP payment for health care in India.

The Direct Effect of Taxes and Transfers on Changes in the U.S. Income Distribution, 1967-2015.

Scholars have increasingly drawn attention to rising levels of income inequality in the United States. However, prior studies have provided an incomplete account of how changes to specific transfer programs have contributed to changes in income growth across the distribution. Our study decomposes the direct effects of tax and transfer programs on changes in the household income distribution from 1967 to 2015. We show that despite a rising Gini coefficient, lower-tail inequality (the ratio of the 50th to 10th percentile) declined in the United States during this period due to the rise of in-kind and tax-based transfers. Food assistance and refundable tax credits account for nearly all the income growth between 1967 and 2015 at the 5th percentile and roughly one-half the growth at the 10th percentile. Moreover, income gains near the bottom of the distribution are concentrated among households with children. Changes in the income distribution were far less progressive among households without children.

The Levels and Trends in Deep and Extreme Poverty in the United States, 1993-2016.

Recently, there has been tremendous interest in deep and extreme poverty in the United States. We advance beyond prior research by using higher-quality data, improving measurement, and following leading standards in international income research. We estimate deep (less than 20% of medians) and extreme (less than 10% of medians) poverty in the United States from 1993 to 2016. Using the Current Population Survey, we match the income definition of the Luxembourg Income Study and adjust for underreporting using the Urban Institute's TRIM3 model. In 2016, we estimate that 5.2 to 7.2 million Americans (1.6% to 2.2%) were deeply poor and 2.6 to 3.7 million (0.8% to 1.2%) were extremely poor. Although deep and extreme poverty fluctuated over time, including declines from 1993 to 1995 and 2007 to 2010, we find significant increases from lows in 1995 to peaks in 2016 in both deep (increases of 48% to 93%) and extreme poverty (increases of 54% to 111%). We even find significant increases with thresholds anchored at 1993 medians. With homelessness added, deep poverty would be 7% to 8% higher and extreme poverty 19% to 23% higher in 2016, which suggests that our estimates are probably lower bounds. The rise of deep/extreme poverty is concentrated among childless households. Among households with children, the expansion of SNAP benefits has led to declines in deep/extreme poverty. Ultimately, we demonstrate that estimates of deep/extreme poverty depend critically on the quality of income measurement.

Living Arrangements and Supplemental Income Programs for Older Adults in Mexico.

Living arrangements often reflect important quality-of-life indicators for elderly adults. In particular, increased income can prompt changes in household living arrangements for elderly adults. Using a differences-in-differences approach, we examine whether a supplemental income program in Mexico for adults aged 70 and older influenced household size and composition. We compare outcomes at baseline and at six-month follow-up for elderly adults in the treatment group with those in the control group that did not participate in the program. We find that household size increased by 3% in the treatment group relative to the control group. We also find a statistically significant increase in the number of girls aged 6-11 in the household, likely the granddaughters or great-granddaughters of program recipients. Increases in household size were greatest for adults aged 70-79, couples, households receiving two or more supplemental incomes, and households in the top income tercile. Household size did not increase for households of adults aged 80 and older, singles, households with only one supplemental income recipient, and households not in the top income tercile. These results suggest that when older adults have more income, they use part of this income to house their grandchildren.

The Association Between Legal Status and Poverty Among Immigrants: A Methodological Caution.

Using nationally representative survey data, this research note examines the association between immigrant legal status and poverty in the United States. Our objective is to test whether estimates of this association vary depending on the method used to infer legal status in survey data, focusing on two approaches in particular: (1) inferring legal status using a logical imputation method that ignores the existence of legal-status survey questions (logical approach); and (2) defining legal status based on survey questions about legal status (survey approach). We show that the two methods yield contrasting conclusions. In models using the logical approach, among noncitizens, being a legal permanent resident (LPR) is counterintuitively associated with a significantly greater net probability of being below the poverty line compared with their noncitizen peers without LPR status. Conversely, using the survey approach to measure legal status, LPR status is associated with a lower net probability of living in poverty, which is in line with a growing body of qualitative and small-sample evidence. Consistent with simulation experiments carried out by Van Hook et al. (2015), the findings call for a more cautious approach to interpreting research results based on legal status imputations and for greater attention to potential biases introduced by various methodological approaches to inferring individuals' legal status in survey data. Consequently, the approach used for measuring legal status has important implications for future research on immigration and legal status.

The Dynamics of U.S. Household Economic Circumstances Around a Birth.

With the arrival of an infant, many households face increased demands on resources, changes in the composition of income, and a potentially heightened risk of income inadequacy. Changing household economic circumstances around a birth have implications for child and family well-being, women's economic security, and public program design, yet have received little research attention in the United States. Using data from the Survey of Income and Program Participation, this study provides new descriptive evidence of month-to-month changes in household income adequacy and the composition of household income in the year before and after a birth. Results show evidence of significant declines in household income adequacy in the months around a birth, particularly for single mothers who live without other adults. Income from public benefit programs buffers but does not eliminate declines in income adequacy. Results have implications for policies targeted at this period, including public benefit and parental leave programs.

Childhood socioeconomic status, comorbidity of chronic kidney disease risk factors, and kidney function among adults in the midlife in the United States (MIDUS) study.

BACKGROUND: There is a lack of empirical effort that systematically investigates the clustering of comorbidity among known risk factors (obesity, hypertension, diabetes, hypercholesterolemia, and elevated inflammation) of chronic kidney disease (CKD) and how different types of comorbidity may link differently to kidney function among healthy adult samples. This study modeled the clustering of comorbidity among risk factors, examined the association between the clustering of risk factors and kidney function, and tested whether the clustering of risk factors was associated with childhood SES. METHODS: The data were from 2118 participants (ages 25-84) in the Midlife in the United States (MIDUS) Study. Risk factors included obesity, elevated blood pressure (BP), high total cholesterol levels, poor glucose control, and increased inflammatory activity. Glomerular filtration rate (eGFR) was estimated from serum creatinine, calculated with the CKD-EPI formula. The clustering of comorbidity among risk factors and its association with kidney function and childhood SES were examined using latent class analysis (LCA). RESULTS: A five-class model was optimal: (1) Low Risk (class size = 36.40%; low probability of all risk factors), (2) Obese (16.42%; high probability of large BMI and abdominally obese), (3) Obese and Elevated BP (13.37%; high probability of being obese and having elevated BP), (4) Non-Obese but Elevated BP (14.95%; high probability of having elevated BP, hypercholesterolemia, and elevated inflammation), and (5) High Risk (18.86%; high probability for all risk factors). Obesity was associated with kidney hyperfiltration, while comorbidity between obesity and hypertension was linked to compromised kidney filtration. As expected, the High Risk class showed the highest probability of having eGFR < 60 ml/min/1.73 m2 (P = .12; 95%CI = .09-.17). Finally, higher childhood SES was associated with reduced probability of being in the High Risk rather than Low Risk class (ß = - 0.20, SE = 0.07, OR [95%CI] = 0.82 [0.71-0.95]). CONCLUSION: These results highlight the importance of considering the impact of childhood SES on risk factors known to be associated with CKD.

Does free public transit increase physical activity and independent mobility in children? Study protocol for comparing children's activity between two Finnish towns with and without free public transit.

BACKGROUND: Children's habitual physical activity, including active travel and catching public transit (walking and cycling to and from destinations), and independent mobility (mobility without an adult) have decreased. Public transit trips are physically active and can provide access to hobbies independent of parents, but there is no device-measured data about children's total physical activity time following the introduction of free public transit. Our aim is to compare physical activity and independent mobility between children living in two Finnish towns, one with a recently introduced free public transit system, and the other without free public transit. METHODS: The city of Mikkeli has provided free public transit for all comprehensive school children since 2017. Various districts from Mikkeli, and the reference town of Kouvola (towns from South-Eastern Finland with a comparative population size and geographical structure), are selected based on their accessibility and the availability of public transit services. Samples of 10-12-year-old children will be recruited through primary schools. We will compare moderate-to-vigorous physical activity time, sitting time (a thigh-worn Fibion® device) and independent mobility (a participatory mapping method, PPGIS) of children: 1) who live in towns with and without free public transit, 2) who live and go to school in districts with high vs. low perceived and objective access to free public transit, and 3) who report using vs. not using free public transit. In addition, ethnography will be used to get insights on the social and cultural effects of the free public transit on children's and parent's everyday life. DISCUSSION: There is a need for scalable solutions that can increase children's physical activity independent of their socioeconomic background or place of residence. This project will give information on how a political action to provide free public transit for children is associated with their total physical activity time and independent mobility patterns, therefore providing highly relevant information for political decision-making and for promoting independent physical activity in children.

Psychological distress among low-income mothers: the role of public and private safety nets.

Poverty is linked with a host of negative outcomes. Approximately one-third of unmarried mothers and their children live in poverty in the United States. Public and private supports have the potential to mitigate the adverse effects of poverty; however, these supports may be unstable over time. The purpose of this study was to determine public and private safety net configurations of low-income mothers longitudinally and test linkages between safety net configurations and maternal psychological distress. Using longitudinal data from the Welfare, Children, Families project conducted in 1999, 2001, and 2005 (n = 1,987), results of multilevel models of change indicated that less than one-half of low-income mothers used public assistance and had private support at any one point. Safety net configurations and psychological distress levels changed over time with deterioration occurring more than improvement, and private safety net availability offered protection from psychological distress. These findings can be used to inform family support services and highlight the need to augment public assistance programs with services aimed to also address maternal psychological well-being and social support. Doing so can be a means of improving the public and private safety nets and outcomes of vulnerable families.

Housing and Urban Development-Veterans Affairs Supportive Housing Vouchers and Veterans' Homelessness, 2007-2017.

Objectives. To determine what role the 88 000 Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) vouchers for permanent supportive housing among US veterans distributed between 2008 and 2017 played in the significant fall in veterans' homelessness over the same time period.Methods. Using a panel data set at the Continuum of Care level over the 2007 to 2017 period, we correlated changes in vouchers with permanent supportive housing units and measures of homelessness. To reduce concerns about omitted variables bias, we used a 2-stage least-squares procedure. The instrument is a Bartik-type shift-share variable. Specifically, for the cumulative vouchers received at the local level, we used the share of the nation's homeless veterans from the local level in the year before the HUD-VASH program multiplied by the cumulative number of vouchers distributed at the national level up to that point.Results. For each additional voucher, permanent supportive housing units increased by 0.9 and the number of homeless veterans decreased by 1.Conclusions. Our results indicate the HUD-VASH program worked as intended and veterans' homelessness would have risen substantially over the past decade without the program.

Planning for Food Access During Emergencies: Missed Meals in Philadelphia.

OBJECTIVES: To illustrate the effects that minor social or environmental disruptions could have on the food access of low-income households in Philadelphia, Pennsylvania, and provide suggestions for how cities can better incorporate food into emergency planning. METHODS: Using publicly available data and stakeholder interviews (n = 8) in 2017, we projected the number of meals that would be missed during environmental and social disruptions in Philadelphia, a major US city with a high poverty rate. RESULTS: As our projections in Philadelphia indicate, even just 3 days of school closures could result in as many as 405 600 missed meals for school-aged children. CONCLUSIONS: These scenarios provide valuable lessons for other cities to proactively plan for food access continuity in times of uncertainty. Public Health Implications. City planners and other city agencies need to include food as a routine part of emergency planning and redefine the threshold at which emergency response protocols are triggered to better ensure protection of low-income and underserved populations.

Money speaks: Reductions in severe food insecurity follow the Canada Child Benefit.

Food insecurity is a pervasive public health problem in high income countries, disproportionately affecting households with children. Though it has been strongly linked with socioeconomic status and investments in social protection programs, less is known about its sensitivity to specific policy interventions, particularly among families. We implemented a difference-in-difference (DID) design to assess whether Canadian households with children experienced reductions in food insecurity compared to those without following the roll-out of a new country-wide income transfer program: the Canada Child Benefit (CCB). Data were derived from the 2015-2018 cycles of Canadian Community Health Survey. We used multinomial logistic regressions to test the association between CCB and food insecurity among three samples: households reporting any income (N = 41,455), the median income or less (N = 18,191) and the Low Income Measure (LIM) or less (N = 7579). The prevalence and severity of food insecurity increased with economic vulnerability, and were both consistently higher among households with children. However, they also experienced significantly greater drops in the likelihood of experiencing severe food insecurity following CCB; most dramatically among those reporting the LIM or less (DID: -4.7%, 95% CI: -8.6, -0.7). These results suggest that CCB disproportionately benefited families most susceptible to food insecurity. Furthermore, our findings also indicate that food insecurity may be impacted by even modest changes to economic circumstance, speaking to the potential of income transfers to help people meet their basic needs.

A Randomized Controlled Trial of a Rapid Re-housing Intervention for Homeless Persons Living with HIV/AIDS: Impact on Housing and HIV Medical Outcomes.

We conducted a randomized controlled trial to determine whether, for homeless persons living with HIV/AIDS (PLWHA), rapid re-housing can improve housing and HIV viral suppression more than standard housing assistance. We recruited 236 PLWHA from HIV emergency housing in New York City (NYC) and randomized them to: (1) Enhanced Housing Placement Assistance (EHPA), i.e., immediate assignment to a case manager to rapidly re-house the client and provide 12 months of case management or (2) usual services, i.e., referral to an NYC housing placement program for which all HIV emergency housing residents were eligible. We compared time to stable housing placement and percentage virally suppressed from baseline to 12 months. EHPA clients were placed faster than usual services clients (p = 0.02; 25% placed by 150 days vs. 243 days, respectively), more likely to be placed [adjusted hazards ratio = 1.8; 95% confidence interval(CI) 1.1-2.8], and twice as likely to achieve or maintain suppression (adjusted odds ratio 2.1; 95% CI 1.1-4.0).

Improving birth outcomes for women who are substance using or have mental illness: a Canadian cohort study comparing antenatal midwifery and physician models of care for women of low socioeconomic position.

BACKGROUND: Some observational studies have shown improved birth outcomes for women of low socioeconomic position (SEP) receiving antenatal midwifery versus physician care. To understand for whom and under what circumstances midwifery care is associated with better birth outcomes we examined whether psychosocial risk including substance use, mental illness, social assistance, residence in a neighbourhood of low/moderate SEP, and teen maternal age modified the association between model of care (midwifery versus physician) and small-for-gestational-age (SGA) or preterm birth (PTB) for women of low SEP. METHODS: For this retrospective cohort study, maternity data from the British Columbia Perinatal Data Registry were linked with Medical Services Plan billing data. We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for SGA birth (< the 10th percentile) and PTB (< 37 weeks' completed gestation). For tests of interaction between antenatal models of care and psychosocial risk, p-values < 0.10 were considered statistically significant. Women were eligible for inclusion if they were residents of British Columbia, Canada, carried a singleton fetus, had low to moderate medical/obstetric risk, birthed between April 1, 2008 and Dec. 31, 2012, and received a health insurance subsidy (n = 33,937). RESULTS: Midwifery versus obstetrician patients had lower odds of PTB. The difference was 31% larger among substance users (aOR 0.24, 95% CI: 0.11-0.54) compared to non-substance users (aOR 0.55, 95% CI: 0.45-0.68). Additionally, there was a 34% statistically significant absolute difference in odds of PTB for midwifery versus obstetrician patients with both mental illness and substance use (aOR 0.18, 95% CI: 0.06-0.55) compared to women with neither mental illness nor substance use (aOR 0.52, 95% CI: 0.41-.66). Results demonstrated a consistent association between midwifery versus physician care and lower odds of SGA, yet effects were not statistically significantly different for women with higher or lower psychosocial risk. CONCLUSION: Among low SEP women in British Columbia, Canada, antenatal midwifery compared to obstetrician care was associated with reduced odds of PTB. Odds were lower among women with substance use, and mental illness and substance use, than among women without these risk factors.