The end of court-ordered desegregation and U.S. children's health: Quasi-experimental evidence.

School racial segregation significantly impacts racial disparities in U.S. children's health. Recently, school segregation has been increasing, partially due to Supreme Court decisions since 1991 that have made it easier for school districts to be released from court-ordered desegregation. We investigated the association of the end of court-ordered desegregation with child health using the 1997-2018 waves of the National Health Interview Survey (N=8,182 Black, 16,930 White children). We exploited quasi-random variation in the timing of school districts' releases from court orders to estimate effects on general health, body weight, mental health, and asthma, using difference-in-differences and event-study methods (including traditional and heterogeneity-robust estimators). Heterogeneity-robust difference-in-differences analyses show that release was associated with increased school segregation, improved mental health among Black children, and better self-reported health among White children. For heterogeneity-robust event-study analyses, school segregation increased steadily over time after release, with worse self-reported health and higher risk of asthma episodes among Black children 18+ years after release. Black children's mental health temporarily improved in the short term. In contrast, White children had improved self-reported health, mental health, and risk of asthma episodes in some years. Interventions to address the harms of school segregation are important for reducing racial health inequities.

Mediating pathways between neighborhood disadvantage and cardiovascular risk: Quasi-experimental evidence from a Danish refugee dispersal policy.

Research has documented that neighborhood disadvantage is associated with increased cardiovascular disease risk, but it is unclear which mechanistic pathways mediate this association across the life course. Leveraging a natural experiment in which refugees to Denmark were quasi-randomly assigned to neighborhoods across the country during 1986-1998 and using 30 years of follow-up data from population and health registers, we assessed whether and how individual-level poverty, unstable employment, and poor mental health mediate the relation between neighborhood disadvantage and the risk of hypertension, hyperlipidemia, and type 2 diabetes among Danish refugees (N= 40,811). Linear probability models using the discrete time-survival framework showed that neighborhood disadvantage was associated with increased risk of hypertension (0.05 percentage points [pp] per year [95%CI -0.00, 0.10]); hyperlipidemia (0.03 pp per year [95%CI -0.01, 0.07]), and diabetes (0.01 pp per year (95%CI -0.02, 0.03)). The Baron-Kenny product-of-coefficients method for counterfactual mediation analysis indicated that cumulative income mediated 6%-28% of the disadvantage effect on these outcomes. We find limited evidence of mediation by unstable employment and poor mental health. This study informs our theoretical understanding of the pathways linking neighborhood disadvantage with cardiovascular disease risk and identifies income security as a promising point of intervention in future research.

Advances in Difference-in-differences Methods for Policy Evaluation Research.

Difference-in-differences (DiD) is a powerful, quasi-experimental research design widely used in longitudinal policy evaluations with health outcomes. However, DiD designs face several challenges to ensuring reliable causal inference, such as when policy settings are more complex. Recent economics literature has revealed that DiD estimators may exhibit bias when heterogeneous treatment effects, a common consequence of staggered policy implementation, are present. To deepen our understanding of these advancements in epidemiology, in this methodologic primer, we start by presenting an overview of DiD methods. We then summarize fundamental problems associated with DiD designs with heterogeneous treatment effects and provide guidance on recently proposed heterogeneity-robust DiD estimators, which are increasingly being implemented by epidemiologists. We also extend the discussion to violations of the parallel trends assumption, which has received less attention. Last, we present results from a simulation study that compares the performance of several DiD estimators under different scenarios to enhance understanding and application of these methods.

Maternal health during the COVID-19 pandemic in the U.S.: an interrupted time series analysis.

BACKGROUND: The COVID-19 pandemic, and subsequent policy responses aimed at curbing disease spread and reducing economic fallout, had far-reaching consequences for maternal health. There has been little research to our knowledge on enduring disruptions to maternal health trends beyond the early pandemic, and limited understanding of how these impacted pre-existing disparities in maternal health. METHODS: We leveraged rigorous interrupted time-series methods and US National Center for Health Statistics Vital Statistics Birth Data Files of all live births for 2015-2021 (N = 24,653,848) and estimated whether changes in maternal health trends after the onset of the COVID-19 pandemic (March 2020) differed from predictions based on pre-existing temporal trends. Outcomes included gestational diabetes, hypertensive disorders of pregnancy, gestational weight gain, and adequacy of prenatal care. RESULTS: We found increased incidence of gestational diabetes (December 2020 peak:1.7 percentage points (pp); 95%CI: 1.3, 2.1), hypertensive disorders of pregnancy (January 2021 peak: 1.3 pp; 95%CI: 0.4, 2.1), and gestational weight gain (March 2021 peak: 0.1 standard deviation (SD); 95%CI: 0.03, 0.1), and declines in inadequate prenatal care (January 2021 nadir: -0.4pp; 95%CI: -0.7, -0.1). Key differences by subgroups included greater and more sustained increases in gestational diabetes among Black, Hispanic, and less educated individuals. CONCLUSION: These patterns in maternal health likely reflect not only effects of COVID-19 infection, but also changes in healthcare access, health behaviors, remote work, economic security, and maternal stress. Further research about causal pathways and longer-term trends will inform public health and clinical interventions to address maternal disease burden and disparities.

The association of increased SNAP benefits during COVID-19 with food insufficiency and anxiety among US adults: a quasi-experimental study.

OBJECTIVES: The COVID-19 pandemic and subsequent policy response to mitigate disease spread had far-reaching impacts on health and social well-being. In response, the Supplemental Nutrition Assistance Program (SNAP) underwent several pandemic-era modifications, including a 15 % monthly benefit increase on January 1, 2021. Research documenting the health effects of these SNAP modifications among low-income households and minoritized groups who were most impacted by the economic fallout during the first years of the pandemic is lacking. We aimed to estimate the health effects of the 15 % SNAP benefit increase in January 2021, among SNAP-eligible US households. DESIGN: We estimated the effects of the SNAP increase on food insufficiency, mental health, and financial well-being using a rigorous quasi-experimental difference-in-differences (DID) analysis. SETTING: August 19, 2020, to March 29, 2021. PARTICIPANTS: Participants were drawn from the national US Census Bureau Household Pulse Survey waves 13-27 (n 44 477). RESULTS: Compared with SNAP-eligible non-recipients, SNAP-eligible recipients experienced decreased food insufficiency (-1·9 percentage points (pp); 95 % CI -3·7, -0·1) and anxiety symptoms (-0·09; 95 % CI -0·17, -0·01), and less difficulty paying for other household expenses (-3·2 pp; 95 % CI -4·9, -1·5) after the SNAP benefit increase. Results were robust to alternative specifications. CONCLUSIONS: Expansions of federal nutrition programmes have the potential to improve health and financial well-being. This study provides timely evidence to inform comprehensive safety net nutrition policies during future economic crises and public health preparedness response plans.

Medicaid Expansion and Perinatal Health Outcomes: A Quasi-Experimental Study.

OBJECTIVE: There has been little evidence of the impact of preventive services during pregnancy covered under the Affordable Care Act (ACA) on birthing parent and infant outcomes. To address this gap, this study examines the association between Medicaid expansion under the ACA and birthing parent and infant outcomes of low-income pregnant people. METHODS: This study used individual-level data from the 2004-2017 annual waves of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is a surveillance project of the Centers for Disease Control and Prevention and health departments that annually includes a representative sample of 1,300 to 3,400 births per state, selected from birth certificates. Birthing parents' outcomes of interest included timing of prenatal care, gestational diabetes, hypertensive disorders of pregnancy, cigarette smoking during pregnancy, and postpartum care. Infant outcomes included initiation and duration of breastfeeding, preterm birth, and birth weight. The association between ACA Medicaid expansion and the birthing parent and infant outcomes were examined using difference-in-differences estimation. RESULTS: There was no association between Medicaid expansion and the outcomes examined after correcting for multiple testing. This finding was robust to several sensitivity analyses. CONCLUSIONS FOR PRACTICE: Study findings suggest that expanded access to more complete insurance benefits with limited cost-sharing for pregnant people, a group that already had high rates of insurance coverage, did not impact the birthing parents' and infant health outcomes examined.

Associations of U.S. state-level COVID-19 policies intensity with cannabis sharing behaviors in 2020.

BACKGROUND: Cannabis use before the COVID-19 pandemic for many involved sharing prepared cannabis for inhalation, practices that were less prevalent during the pandemic. State-level COVID-19 containment policies may have influenced this decrease. This study examined the extent to which the intensity of state-level COVID-19 policies were associated with individual-level cannabis sharing. Findings have the potential to guide harm reduction policies for future respiratory pandemics and seasonal respiratory virus waves. METHODS: This study used cross-sectional individual-level data from the COVID-19 Cannabis Study, an anonymous U.S.-based web survey on cannabis use disseminated during the early phase of the pandemic (Full sample N = 1,883). We combined individual-level data with state-level policy data from Kaiser Family Foundation's State COVID-19 Data and Policy Actions for three time-points from June to August 2020 that overlapped with the survey period. Cannabis sharing was dichotomized as any versus no sharing. We adapted a previously published coding framework to score the intensity of COVID-19 policies implemented in each U.S. state and averaged the policy score across the time period. We then used Poisson regression models to quantify the associations of the average state-level COVID-19 policy score with cannabis sharing during the pandemic. RESULTS: Participants (n = 925) reporting using inhalation as a mode for cannabis use were included in this analysis. Most respondents were male (64.1%), non-Hispanic White (54.3%), with a mean age of 33.7 years (SD 8.8). A large proportion (74.9%) reported sharing cannabis during the pandemic. Those who shared cannabis more commonly lived in states with a lower average policy score (16.7, IQR 12.3-21.5) compared to those who did not share (18.6, IQR 15.3-25.3). In adjusted models, the prevalence ratio of any cannabis sharing per every 5-unit increase in the average COVID-19 policy score was 0.97 (95% CI 0.93, 1.01). CONCLUSIONS: Fewer individuals shared cannabis in states with more intense COVID-19 containment policies compared to those in states with less intense policies. Individuals who use cannabis may be willing to make changes to their behavior and may further benefit from specific and directed public health messaging to avoid sharing during respiratory infection outbreaks.

The Pent-Up Demand for Breastfeeding Among US Women: Trends After COVID-19 Shelter-in-Place.

Objectives. To estimate changes in national breastfeeding trends immediately before and after COVID-19‒related workplace closures in early 2020. Methods. The implementation of shelter-in-place policies in early 2020, when 90% of people in the United States were urged to remain at home, represents a unique natural experiment to assess the pent-up demand for breastfeeding among US women that may be stymied by the lack of a national paid leave policy. We used the 2017-2020 Pregnancy Risk Assessment Monitoring System (n = 118 139) to estimate changes in breastfeeding practices for births occurring before and after shelter-in-place policies were implemented in the United States. We did this in the overall sample and by racial/ethnic and income subgroups. Results. There was no change in breastfeeding initiation and a 17.5% increase in breastfeeding duration after shelter-in-place, with lingering effects through late 2020. High-income and White women demonstrated the largest gains. Conclusions. The United States ranks worse than similar countries when it comes to breastfeeding initiation and duration. This study suggests that this is partly attributable to inadequate access to postpartum paid leave. This study also demonstrates inequities introduced by patterns of remote work during the pandemic. (Am J Public Health. 2023;113(8):870-873. https://doi.org/10.2105/AJPH.2023.307313).

Promoting health equity through poverty alleviation policy: Factors associated with receipt of the 2021 U.S. Child Tax Credit in a nationwide sample.

INTRODUCTION: The 2021 temporary expansion of the U.S. Child Tax Credit (CTC) was a potent policy that addressed poverty as a critical social determinant of health. Yet policies can only have their intended effects if they are implemented appropriately, and it is well known that not all who were eligible for the CTC received it. In this study, we investigated which individual- and state-level factors were correlated with receipt of the 2021 expanded CTC among eligible families. METHODS: We used data from the U.S. Census Bureau Household Pulse Survey and included 76,994 CTC-eligible individuals. We used multivariable logistic regressions to evaluate individual- and state-level factors associated with self-reported CTC receipt during July-December 2021. RESULTS: Roughly two-thirds of the CTC-eligible sample reported CTC receipt. CTC receipt was higher among eligible individuals who were female, aged 35-44 years (relative to younger individuals), Black, and married. Receipt was also higher among those with at least some college education, two or more children, and family income above $25,000, and among recipients of the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. For state-level factors, SNAP and Medicaid caseloads and the state earned income tax credit rate were associated with decreased receipt. CONCLUSION: As Congress debates whether to make the CTC expansion permanent, this study provides timely evidence to inform poverty alleviation programs to increase participation among eligible and marginalized groups and achieve health equity.

The effect of the 2009 revised U.S. guidelines for gestational weight gain on maternal and infant health: a quasi-experimental study.

BACKGROUND: Excess gestational weight gain (GWG) has adverse short- and long-term effects on the health of mothers and infants. In 2009, the US Institute of Medicine revised its guidelines for GWG and reduced the recommended GWG for women who are obese. There is limited evidence on whether these revised guidelines affected GWG and downstream maternal and infant outcomes. METHODS: We used data from the 2004-2019 waves of the Pregnancy Risk Assessment Monitoring System, a serial cross-sectional national dataset including over 20 states. We conducted a quasi-experimental difference-in-differences analysis to assess pre/post changes in maternal and infant outcomes among women who were obese, while "differencing out" the pre/post changes among a control group of women who were overweight. Maternal outcomes included GWG and gestational diabetes; infant outcomes included preterm birth (PTB), low birthweight (LBW), and very low birthweight (VLBW). Analysis began in March 2021. RESULTS: There was no association between the revised guidelines and GWG or gestational diabetes. The revised guidelines were associated with reduced PTB (- 1.19% points, 95%CI: - 1.86, - 0.52), LBW (- 1.38% points 95%CI: - 2.07, - 0.70), and VLBW (- 1.30% points, 95%CI: - 1.68, - 0.92). Results were robust to several sensitivity analyses. CONCLUSION: The revised 2009 GWG guidelines were not associated with changes in GWG or gestational diabetes but were associated with improvements in infant birth outcomes. These findings will help inform further programs and policies aimed at improving maternal and infant health by addressing weight gain in pregnancy.

Potential mechanisms linking poverty alleviation and health: an analysis of benefit spending among recipients of the U.S. earned income tax credit.

BACKGROUND: The earned income tax credit (EITC) is the largest U.S. poverty alleviation program for low-income families, disbursed annually as a lump-sum tax refund. Despite its well-documented health impacts, the mechanisms through which the EITC affects health are not well understood. The objective of this analysis was to examine self-reported spending patterns of tax refunds among EITC recipients to clarify potential pathways through which income may affect health. METHODS: We first examined spending patterns among 2020-2021 Assessing California Communities' Experiences with Safety Net Supports (ACCESS) study participants (N = 241) and then stratified the analysis by key demographic subgroups. RESULTS: More than half of EITC recipients reported spending their tax refunds on bills and debt (52.3%), followed by 49.4% on housing, and 37.8% on vehicles. Only 3.3% reported spending on healthcare. (Note: respondents could list more than one possible spending category.) Participants ages 30 + were more likely to spend on bills and debt relative to those ages 18-29 (57.6% versus 39.4%, respectively). Other subgroup analyses did not yield significant findings. CONCLUSIONS: Our findings suggest that EITC recipients primarily use their refunds on bills and debt, as well as on household and vehicle expenses. This supports the idea of the EITC as a safety net policy which addresses key social determinants of health.

Comparing the health of refugee and asylee patients with that of non-refugee immigrant and US-born patients in a large Urban clinic.

OBJECTIVES: To compare disease burden in refugee/asylee, non-refugee immigrant, and US-born patients in the largest safety net clinic in San Francisco, California. METHODS: This is a retrospective chart review including 343 refugee/asylee, 450 immigrant, and 202 US-born patients in a San Francisco clinic from January 2014 to December 2017. Using electronic medical records, we compared prevalence of several diseases by immigration status. Using Poisson regression models with robust variance, we assessed association of diseases with immigration status, adjusting for sociodemographic characteristics. RESULTS: Diagnoses of non-communicable chronic diseases were less common in refugees/asylees, who had a greater risk of being diagnosed with mental health conditions. In Poisson regression models adjusted for sociodemographic characteristics, compared with refugees/asylees, US-born patients were more likely to have hypertension (IRR[CI] = 1.8 [1.0, 3.7]) and less likely to have depression (IRR[CI] = 0.5 [0.3, 0.8]). US-born (IRR[CI] = 0.06 [0.01, 0.2]) and immigrant patients (IRR[CI] = 0.1 [0.06, 0.2]) were less likely to have post-traumatic stress disorder. CONCLUSIONS: We uncover differences in burden of non-communicable chronic diseases and mental health by immigration status. These results highlight the importance of clinical screenings and research on disease burden in refugees.

Experiences of distress and gaps in government safety net supports among parents of young children during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The COVID-19 pandemic prompted rapid federal, state, and local government policymaking to buffer families from the health and economic harms of the pandemic. However, there has been little attention to families' perceptions of whether the pandemic safety net policy response was adequate, and what is needed to alleviate lasting effects on family well-being. This study examines the experiences and challenges of families with low incomes caring for young children during the pandemic. METHODS: Semi-structured qualitative interviews conducted from August 2020 to January 2021 with 34 parents of young children in California were analyzed using thematic analysis. RESULTS: We identified three key themes related to parents' experiences during the pandemic: (1) positive experiences with government support programs, (2) challenging experiences with government support programs, and (3) distress resulting from insufficient support for childcare disruptions. Participants reported that program expansions helped alleviate food insecurity, and those attending community colleges reported accessing a range of supports through supportive counselors. However, many reported gaps in support for childcare and distance learning, pre-existing housing instability, and parenting stressors. With insufficient supports, additional childcare and education workloads resulted in stress and exhaustion, guilt about competing demands, and stagnation of longer-term goals for economic and educational advancement. CONCLUSIONS: Families of young children, already facing housing and economic insecurity prior to the pandemic, experienced parental burnout. To support family well-being, participants endorsed policies to remove housing barriers, and expand childcare options to mitigate job loss and competing demands on parents. Policy responses that either alleviate stressors or bolster supports have the potential to prevent distress catalyzed by future disasters or the more common destabilizing experiences of economic insecurity.

Estimating the effect of timing of earned income tax credit refunds on perinatal outcomes: a quasi-experimental study of California births.

BACKGROUND: The largest poverty alleviation program in the US is the earned income tax credit (EITC), providing $60 billion to over 25 million families annually. While research has shown positive impacts of EITC receipt in pregnancy, there is little evidence on whether the timing of receipt may lead to differences in pregnancy outcomes. We used a quasi-experimental difference-in-differences design, taking advantage of EITC tax disbursement each spring to examine whether trimester of receipt was associated with perinatal outcomes. METHODS: We conducted a difference-in-differences analysis of California linked birth certificate and hospital discharge records. The sample was drawn from the linked CA birth certificate and discharge records from 2007-2012 (N = 2,740,707). To predict eligibility, we created a probabilistic algorithm in the Panel Study of Income Dynamics and applied it to the CA data. Primary outcome measures included preterm birth, small-for-gestational age (SGA), gestational diabetes, and gestational hypertension/preeclampsia. RESULTS: Eligibility for EITC receipt during the third trimester was associated with a lower risk of preterm birth compared with preconception. Eligibility for receipt in the preconception period resulted in improved gestational hypertension and SGA. CONCLUSION: This analysis offers a novel method to impute EITC eligibility using a probabilistic algorithm in a data set with richer sociodemographic information relative to the clinical and administrative data sets from which outcomes are drawn. These results could be used to determine the optimal intervention time point for future income supplementation policies. Future work should examine frequent income supplementation such as the minimum wage or basic income programs.

Neighbourhood socioeconomic disadvantage and psychiatric disorders among refugees: a population-based, quasi-experimental study in Denmark.

PURPOSE: Refugees are vulnerable to psychiatric disorders because of risk factors linked to migration. Limited evidence exist on the impact of the neighbourhood in which refugee resettle. We examined whether resettling in a socioeconomically disadvantaged neighbourhood increased refugees' risk of psychiatric disorders. METHODS: This register-based cohort study included 42,067 adults aged 18 years and older who came to Denmark as refugees during 1986-1998. Resettlement policies in those years assigned refugees in a quasi-random fashion to neighbourhoods across the country. A neighbourhood disadvantage index was constructed using neighbourhood-level data on income, education, unemployment, and welfare receipt. Main outcomes were psychiatric diagnoses and psychiatric medication usage ascertained from nationwide patient and prescription drug registers, with up to 30-year follow-up. Associations of neighbourhood disadvantage with post-migration risk of psychiatric disorders were examined using Cox proportional hazards and linear probability models adjusted for individual, family, and municipality characteristics. RESULTS: The cumulative risk of psychiatric diagnoses and medication was 13.7% and 46.1%, respectively. Refugees' risk of psychiatric diagnoses and psychiatric medication usage was higher among individuals assigned to high-disadvantage compared with low-disadvantage neighbourhoods in analyses including fixed effects for assigned municipality (psychiatric diagnoses: hazard ratio (HR) = 1.14, 95% CI 1.04, 1.25; psychiatric medication: HR = 1.05, 95% CI 1.00, 1.11). Consistent results were found using linear probability models. Results for diagnostic categories and subclasses of medications suggested that the associations were driven by neurotic and stress-related disorders and use of anxiolytic medications. CONCLUSION: Resettlement in highly disadvantaged neighbourhoods was associated with an increase in refugees' risk of psychiatric disorders, suggesting that targeted placement of newly arrived refugees could benefit refugee mental health. The results contribute quasi-experimental evidence to support links between neighbourhood characteristics and health.

Racial and sociodemographic predictors of COVID-19 compared with influenza, appendicitis, and all-cause hospitalization: retrospective cohort analysis.

OBJECTIVE: To determine whether inequities in COVID-19 infection and hospitalization differ from those for common medical conditions: influenza, appendicitis, and all-cause hospitalization. DESIGN: Retrospective study based on electronic health records of three healthcare systems in San Francisco (university, public, and community) examining (1) racial/ethnic distribution in cases and hospitalization among patients with diagnosed COVID-19 (March-August 2020) and patients with diagnosed influenza, diagnosed appendicitis, or all-cause hospitalization (August 2017-March 2020), and (2) sociodemographic predictors of hospitalization among those with diagnosed COVID-19 and influenza. RESULTS: Patients 18 years or older with diagnosed COVID-19 (N = 3934), diagnosed influenza (N = 5932), diagnosed appendicitis (N = 1235), or all-cause hospitalization (N = 62,707) were included in the study. The age-adjusted racial/ethnic distribution of patients with diagnosed COVID-19 differed from that of patients with diagnosed influenza or appendicitis for all healthcare systems, as did hospitalization from these conditions compared to any cause. For example, in the public healthcare system, 68% of patients with diagnosed COVID-19 were Latine, compared with 43% of patients with diagnosed influenza, and 48% of patients with diagnosed appendicitis (p < 0.05). In multivariable logistic regressions, COVID-19 hospitalizations were associated with male sex, Asian and Pacific Islander race/ethnicity, Spanish language, and public insurance in the university healthcare system, and Latine race/ethnicity and obesity in the community healthcare system. Influenza hospitalizations were associated with Asian and Pacific Islander and other race/ethnicity in the university healthcare system, obesity in the community healthcare system, and Chinese language and public insurance in both the university and community healthcare systems. CONCLUSIONS: Racial/ethnic and sociodemographic inequities in diagnosed COVID-19 and hospitalization differed from those for diagnosed influenza and other medical conditions, with consistently higher odds among Latine and Spanish-speaking patients. This work highlights the need for disease-specific public health efforts in at-risk communities in addition to structural upstream interventions.

Understanding the Predictors of Low Take-Up of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): A Nationwide Longitudinal Study.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is among the largest U.S. social safety net programs. Although strong evidence exists regarding the benefits of WIC, take-up (i.e., participation among eligible individuals) has steadily declined in the past decade. This study addresses gaps in our knowledge regarding predictors of WIC take-up during this time. METHODS: Data were drawn from the 1998-2017 waves of the National Health Interview Study (NHIS), a serial cross-sectional study of the U.S. POPULATION: The analytic sample included 23,645 children and 10,297 women eligible for WIC based on self-reported demographic characteristics. To investigate predictors of WIC take-up, we regressed self-reported WIC receipt on a range of individual-level predictors (e.g., age, nativity, income) and state- level predictors (e.g., unemployment rate, governor's political affiliation) using multivariable logistic regression. In secondary analyses, results were additionally stratified by race/ethnicity, time period, and age (for children). RESULTS: For both women and children, older maternal age and higher educational attainment were associated with decreased take-up of WIC. Associations differed by race/ethnicity, time period, and state characteristics including caseload of other social programs (e.g., Medicaid). DISCUSSION: Our study identifies groups that are less likely to take up WIC benefits for which they are eligible, thereby contributing important evidence to inform programs and policies to increase WIC participation among groups with lower take-up. As WIC evolves past the COVID-19 pandemic, special attention will be needed to ensure that resources to encourage and support the participation of racially and economically marginalized individuals are equitably distributed.

School racial segregation and long-term cardiovascular health among Black adults in the US: A quasi-experimental study.

BACKGROUND: Cardiovascular disease (CVD) disproportionately affects Black adults in the United States. This is increasingly acknowledged to be due to inequitable distribution of health-promoting resources. One potential contributor is inequities in educational opportunities, although it is unclear what aspects of education are most salient. School racial segregation may affect cardiovascular health by increasing stress, constraining socioeconomic opportunities, and altering health behaviors. We investigated the association between school segregation and Black adults' CVD risk. METHODS AND FINDINGS: We leveraged a natural experiment created by quasi-random (i.e., arbitrary) timing of local court decisions since 1991 that released school districts from court-ordered desegregation. We used the Panel Study of Income Dynamics (PSID) (1991 to 2017), linked with district-level school segregation measures and desegregation court order status. The sample included 1,053 Black participants who ever resided in school districts that were under a court desegregation order in 1991. The exposure was mean school segregation during observed schooling years. Outcomes included several adult CVD risk factors and outcomes. We fitted standard ordinary least squares (OLS) multivariable linear regression models, then conducted instrumental variables (IV) analysis, using the proportion of schooling years spent in districts that had been released from court-ordered desegregation as an instrument. We adjusted for individual- and district-level preexposure confounders, birth year, and state fixed effects. In standard linear models, school segregation was associated with a lower probability of good self-rated health (-0.05 percentage points per SD of the segregation index; 95% CI: -0.08, -0.03; p < 0.001) and a higher probability of binge drinking (0.04 percentage points; 95% CI: 0.002, 0.07; p = 0.04) and heart disease (0.01 percentage points; 95% CI: 0.002, 0.15; p = 0.007). IV analyses also found that school segregation was associated with a lower probability of good self-rated health (-0.09 percentage points; 95% CI: -0.17, -0.02, p = 0.02) and a higher probability of binge drinking (0.17 percentage points; 95% CI: 0.04, 0.30, p = 0.008). For IV estimates, only binge drinking was robust to adjustments for multiple hypothesis testing. Limitations included self-reported outcomes and potential residual confounding and exposure misclassification. CONCLUSIONS: School segregation exposure in childhood may have longstanding impacts on Black adults' cardiovascular health. Future research should replicate these analyses in larger samples and explore potential mechanisms. Given the recent rise in school segregation, this study has implications for policies and programs to address racial inequities in CVD.

Explaining the Variance in Cardiovascular Disease Risk Factors: A Comparison of Demographic, Socioeconomic, and Genetic Predictors.

BACKGROUND: Efforts to explain the burden of cardiovascular disease (CVD) often focus on genetic factors or social determinants of health. There is little evidence on the comparative predictive value of each, which could guide clinical and public health investments in measuring genetic versus social information. We compared the variance in CVD-related outcomes explained by genetic versus socioeconomic predictors. METHODS: Data were drawn from the Health and Retirement Study (N = 8,720). We examined self-reported diabetes, heart disease, depression, smoking, and body mass index, and objectively measured total and high-density lipoprotein cholesterol. For each outcome, we compared the variance explained by demographic characteristics, socioeconomic position (SEP), and genetic characteristics including a polygenic score for each outcome and principal components (PCs) for genetic ancestry. We used R-squared values derived from race-stratified multivariable linear regressions to evaluate the variance explained. RESULTS: The variance explained by models including all predictors ranged from 3.7% to 14.3%. Demographic characteristics explained more than half this variance for most outcomes. SEP explained comparable or greater variance relative to the combination of the polygenic score and PCs for most conditions among both white and Black participants. The combination of SEP, polygenic score, and PCs performed substantially better, suggesting that each set of characteristics may independently contribute to the prediction of CVD-related outcomes. Philip R. Lee Institute for Health Policy Studies, Department of Family & Community Medicine, UCSF. CONCLUSIONS: Focusing on genetic inputs into personalized medicine predictive models, without considering measures of social context that have clear predictive value, needlessly ignores relevant information that is more feasible and affordable to collect on patients in clinical settings. See video abstract at, http://links.lww.com/EDE/B879.

The effect of the 2009 WIC revision on maternal and child health: A quasi-experimental study.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the largest U.S. nutrition program for low-income pregnant women. It was revised in 2009, with the goal of improving nutritional content of food packages, enhancing nutrition education, and strengthening breast feeding support. Few studies have assessed the effects of this revision on perinatal health. OBJECTIVES: To investigate the impact of the revised WIC program on maternal and child health in a large, multi-state data set. METHODS: We conducted a quasi-experimental difference-in-differences analysis, comparing the pre/post changes among WIC recipients to changes among non-recipients. We adjusted for key sociodemographic covariates in multivariable linear models. We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 18 states from 2004 to 2017. RESULTS: The main analysis included 331,946 mother-infant dyads. WIC recipients were more likely to be younger, Black or Hispanic/Latina, unmarried, and of greater parity. The revised WIC program was associated with reduced likelihood of more-than-recommended GWG (-1.29% points, 95% confidence interval [CI] -2.03, -0.56) and increased likelihood of ever breast fed (1.18% points, 95% CI 0.28, 2.08). We also identified heterogeneous effects on GWG, with more pronounced associations among women 35 and older. There were no associations with foetal growth. CONCLUSIONS: The revised WIC program was associated with improvements in women's gestational weight gain and infant breast feeding.