Educational disparities in joint pain within and across US states: do macro sociopolitical contexts matter?

ABSTRACT: Despite growing recognition of the importance of social, economic, and political contexts for population health and health inequalities, research on pain disparities relies heavily on individual-level data, while neglecting overarching macrolevel factors such as state-level policies and characteristics. Focusing on moderate or severe arthritis-attributable joint pain-a common form of pain that considerably harms individuals' quality of life-we (1) compared joint pain prevalence across US states; (2) estimated educational disparities in joint pain across states; and (3) assessed whether state sociopolitical contexts help explain these 2 forms of cross-state variation. We linked individual-level data on 407,938 adults (ages 25-80 years) from the 2017 Behavioral Risk Factor Surveillance System with state-level data on 6 measures (eg, the Supplemental Nutrition Assistance Program [SNAP], Earned Income Tax Credit, Gini index, and social cohesion index). We conducted multilevel logistic regressions to identify predictors of joint pain and inequalities therein. Prevalence of joint pain varies strikingly across US states: the age-adjusted prevalence ranges from 6.9% in Minnesota to 23.1% in West Virginia. Educational gradients in joint pain exist in all states but vary substantially in magnitude, primarily due to variation in pain prevalence among the least educated. At all education levels, residents of states with greater educational disparities in pain are at a substantially higher risk of pain than peers in states with lower educational disparities. More generous SNAP programs (odds ratio [OR] = 0.925; 95% confidence interval [CI]: 0.963-0.957) and higher social cohesion (OR = 0.819; 95% CI: 0.748-0.896) predict lower overall pain prevalence, and state-level Gini predicts higher pain disparities by education.

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

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

Changes in health behaviours during early COVID-19 and socio-demographic disparities: a cross-sectional analysis.

OBJECTIVES: The COVID-19 pandemic has profoundly disrupted daily life in Canada. This study assesses changes in health behaviours during the early stages of the pandemic and examines socio-demographic disparities associated with these changes. METHODS: We analyze data on adults age 25 and older (N = 4383) from the public-use Canadian Perspectives Survey Series 1: Impacts of COVID-19 (CPSS-COVID). Multinomial regression models assess the association between demographic and socio-economic characteristics with increases or decreases in six health behaviours: alcohol, tobacco, and cannabis use, junk food consumption, and TV and internet screen time. RESULTS: While findings varied across the six behaviours, overall, there was an increase in negative health behaviours: 14% of Canadian adults reported increasing their alcohol use (95% CI = 0.12, 0.15), 25% increased their junk food consumption (95% CI = 0.23, 0.27), and over 60% increased their screen time (62%, 95% CI = 0.60, 0.65 for TV and 66%, 95% CI = 0.63, 0.68 for internet). Younger and Canada-born adults were more likely to increase negative health behaviours than older and immigrant Canadians. Adults who reported financial impact of COVID-19 were more likely to increase all negative health behaviours (e.g., for increased junk food consumption, the relative risk ratio (RRR) = 1.81, 95% CI = 1.49, 2.20 relative to group reporting no impact). CONCLUSION: Our study documents the overall deterioration of health behaviours during the early stages of the COVID-19 pandemic. To minimize long-term harm to the Canadian population's health, the results highlight the need to tailor interventions, especially for younger Canadians, and the importance of mitigating financial impacts, which are linked to negative changes in health behaviours.

RéSUMé: OBJECTIFS: La pandémie de COVID-19 perturbe profondément la vie quotidienne au Canada. Notre étude évalue les changements survenus dans les comportements de santé aux premiers stades de la pandémie et examine les disparités sociodémographiques associées à ces changements. MéTHODE: Nous analysons les données sur les adultes de 25 ans et plus (N = 4 383) tirées de la Série d'enquêtes sur les perspectives canadiennes 1 : Répercussions de la COVID-19 (SEPC-COVID) d'usage public. Des modèles de régression multinomiale permettent d'évaluer l'association entre les caractéristiques démographiques et socioéconomiques et les augmentations ou les diminutions de six comportements de santé : usage de l'alcool, du tabac et du cannabis, consommation d'aliments vides et temps passé devant la télévision et sur Internet. RéSULTATS: Nos constatations varient entre ces six comportements, mais dans l'ensemble, il y a eu une augmentation des comportements de santé négatifs : 14 % des Canadiens adultes ont dit avoir accru leur usage de l'alcool (IC de 95 % = 0,12, 0,15), 25 % ont accru leur consommation d'aliments vides (IC de 95 % = 0,23, 0,27), et plus de 60 % ont accru leur temps d'écran (62 %, IC de 95 % = 0,60, 0,65 pour la télévision et 66 %, IC de 95 % = 0,63, 0,68 pour Internet). Les jeunes adultes et les adultes nés au Canada étaient plus susceptibles d'avoir accru leurs comportements de santé négatifs que les adultes âgés et ceux ayant immigré au Canada. Les adultes ayant dit subir des contrecoups financiers de la COVID-19 étaient plus susceptibles d'avoir accru tous leurs comportements de santé négatifs (p. ex., pour la consommation accrue d'aliments vides, le rapport de risque relatif [RRR] = 1,81, IC de 95 % = 1,49, 2,20, comparativement au groupe n'ayant pas subi de contrecoups financiers). CONCLUSION: Notre étude décrit la détérioration globale des comportements de santé aux premiers stades de la pandémie de COVID-19. Pour réduire les torts que cela peut causer à long terme à la santé de la population canadienne, il faut, selon les résultats, adapter les interventions, surtout aux jeunes Canadiens, et atténuer les contrecoups financiers de la pandémie, qui sont liés à des changements négatifs dans les comportements de santé.

US State Policies, Politics, and Life Expectancy.

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

Explaining the increasing disability prevalence among mid-life US adults, 2002 to 2016.

Several recent studies have documented an alarming upward trend in disability and functional limitations among US adults. In this study, we draw on the sociomedical Disablement Process framework to produce up-to-date estimates of the trends and identify key social and medical precursors of the trends. Using data on US adults aged 45-64 in the 2002-2016 National Health Interview Surveys, we estimate parametric and semiparametric models of disability and functional limitations as a function of interview time. We also determine the impact of socioeconomic resources, health behaviors, and health conditions on the trends. Our results show increasing prevalence of disability and functional limitations. These trends reflect the net result of complex countervailing forces, some associated with increases in functioning problems (unfavorable trends in economic well-being, especially income, and psychological distress) while other factors have suppressed the growth of functioning problems (favorable trends in educational attainment and some health behaviors, such as smoking and alcohol use). The results underscore that disability prevention must expand beyond medical interventions to include fundamental social factors and be focused on preventing or delaying the onset of chronic health problems and functional limitations.

Explaining Inequalities in Women's Mortality between U.S. States.

Inequalities in women's mortality between U.S. states are large and growing. It is unknown whether they reflect differences between states in their population characteristics, contextual characteristics, or both. This study systematically examines the large inequalities in women's mortality between U.S. states using a multilevel approach. It focuses on "fundamental" social determinants of mortality at the individual and state levels as potential explanations. We analyze data from the 2013 public-use National Longitudinal Mortality Study on women aged 45-89 years and estimate multilevel logistic regression models. The models include women's personal characteristics (age, race/ethnicity, education, employment, income, and marriage) and states' contextual characteristics (economic environment, social cohesion, sociopolitical orientation, physical infrastructure, and tobacco environment). We found that variation in women's mortality across states was significant (p<0.001). Adjusting for women's personal characteristics explained 30% of the variation. Additionally adjusting for states' contextual characteristics explained 62% of the variation; the most important characteristics were social cohesion and economic conditions. No significant mortality differences between any two states remained after accounting for individual and contextual characteristics. Supplementary analyses of men indicate that state contexts have stronger and more pernicious consequences for women than men. Taken together, the findings underscore the importance of 'bringing context back in' and taking a multilevel approach when investigating geographic inequalities in U.S. mortality.

Employment and income losses among cancer survivors: Estimates from a national longitudinal survey of American families.

BACKGROUND: Cancer presents a substantial hardship for patients and their families in multiple domains beyond health and survival. Relatively little is known about the economic impact of cancer. The authors present estimates of the aggregate effects of a cancer diagnosis on employment and income in a prospective, nationally representative sample of US adults. METHODS: The authors used data from the 1990 through 2009 waves of the Panel Study of Income Dynamics, a nationally representative, prospective, population-based observational study with high-quality individual and family-level economic information. Age-adjusted, sex-stratified, individual fixed-effects regression models were used to derive estimates of the impact of cancer on employment, hours worked, individual income, and total family income. RESULTS: Significant effects of cancer on all 4 outcomes were observed. The probability of a cancer patient being employed dropped by almost 10 percentage points, and hours worked declined by up to 200 hours in the first year after diagnosis. Annual labor-market earnings dropped almost 40% within 2 years after diagnosis and remained low, whereas total family income declined by 20%, although it recovered within 4 years after the diagnosis. These economic impacts on survivors were driven by effects among men; the effects among women largely were not statistically significant. CONCLUSIONS: A cancer diagnosis has substantial effects on the economic well-being of affected adults and their families. With the increasing number of cancer survivors in the US population, there is a growing need for examining the long-term implications for economic well-being and ways to mitigate the economic hardship associated with cancer.

Accuracy of Telehealth-Administered Measures to Screen Language in Spanish-Speaking Preschoolers.

INTRODUCTION: There is a critical need for telehealth language screening measures for use with Spanish-speaking children because of the shortage of bilingual providers and the current lack of psychometrically sound measures that can be administered via telehealth. The purpose of the current study was to describe the classification accuracy of individual telehealth language screening measures as well as the accuracy of combinations of measures used with Spanish-speaking preschoolers from rural and underserved areas of the country. MATERIALS AND METHODS: This study applied a hybrid telehealth approach that implemented synchronous videoconferencing, videocasting, and traditional pen and paper measures. Screening measures included a processing efficiency measure (Spanish nonword repetition [NWR]), language sampling, and a developmental language questionnaire. Eighty-two mostly Spanish-speaking preschool-age children and their parents participated. Thirty-four children had language impairment (LI), and 48 had typical language development. RESULTS: Although many of the individual measures were significantly associated with standardized language scores (r=0.27-0.55), not one of the measures had classification values of 0.8 or higher, which is recommended when screening for LI. However, when NWR scores were combined with language sample or parent survey measures, promising classification accuracy values that approached or were higher than 0.8 were obtained. CONCLUSIONS: This research provides preliminary evidence showing the effectiveness of a hybrid telehealth model in screening the language development of Spanish-speaking children. A processing efficiency measure, NWR, combined with a parent survey or language sample measure can provide informative and accurate diagnostic information when screening Spanish-speaking preschool-age children for LI.

Explaining the widening education gap in mortality among U.S. white women.

Over the past half century the gap in mortality across education levels has grown in the United States, and since the mid-1980s, the growth has been especially pronounced among white women. The reasons for the growth among white women are unclear. We investigated three explanations-social-psychological factors, economic circumstances, and health behaviors-for the widening education gap in mortality from 1997 to 2006 among white women aged 45 to 84 years using data from the National Health Interview Survey Linked Mortality File (N = 46,744; 4,053 deaths). Little support was found for social-psychological factors, but economic circumstances and health behaviors jointly explained the growing education gap in mortality to statistical nonsignificance. Employment and smoking were the most important individual components. Increasing high school graduation rates, reducing smoking prevalence, and designing work-family policies that help women find and maintain desirable employment may reduce mortality inequalities among women.

Trends in mortality risk by education level and cause of death among US White women from 1986 to 2006.

OBJECTIVES: To elucidate why the inverse association between education level and mortality risk (the gradient) has increased markedly among White women since the mid-1980s, we identified causes of death for which the gradient increased. METHODS: We used data from the 1986 to 2006 National Health Interview Survey Linked Mortality File on non-Hispanic White women aged 45 to 84 years (n = 230 692). We examined trends in the gradient by cause of death across 4 time periods and 4 education levels using age-standardized death rates. RESULTS: During 1986 to 2002, the growing gradient for all-cause mortality reflected increasing mortality among low-educated women and declining mortality among college-educated women; during 2003 to 2006 it mainly reflected declining mortality among college-educated women. The gradient increased for heart disease, lung cancer, chronic lower respiratory disease, cerebrovascular disease, diabetes, and Alzheimer's disease. Lung cancer and chronic lower respiratory disease explained 47% of the overall increase. CONCLUSIONS: Mortality disparities among White women widened across 1986 to 2006 partially because of causes of death for which smoking is a major risk factor. A comprehensive policy framework should address the social conditions that influence smoking among disadvantaged women.

Predictors of inflammation in U.S. children aged 3-16 years.

BACKGROUND: Little is known about the correlates of low-grade inflammation in U.S. children. PURPOSE: This study describes the factors associated with increased levels of C-reactive protein (CRP) in U.S. children and tests whether differences in CRP emerge in childhood because of socioeconomic factors. METHODS: Data were analyzed in 2009 from 6004 children aged 3-16 years from the National Health and Nutrition Examination Survey, 1999-2004, a representative sample of the U.S. non-institutionalized population. Tobit regression models are used to evaluate associations between predictors, including BMI-for-age, skinfold body fat measures, chronic infections, environmental tobacco exposure, low birth weight, and sociodemographics and continuous high-sensitivity CRP in milligrams per liter. RESULTS: CRP levels were higher in U.S. children with lower family income, and these differences were largely accounted for by differences in adiposity and recent illness. Mexican-American children had higher levels of CRP compared to both whites and blacks, but these differences were not explained by measured physical risk factors. CONCLUSIONS: Increased adiposity is associated with higher CRP concentrations in U.S children aged 3-16 years, and both socioeconomic and racial/ethnic differences exist in systemic inflammation in U.S. children. Increased childhood obesity and low-grade inflammation may contribute to later life chronic disease risk.

Consistency and precision of cancer reporting in a multiwave national panel survey.

BACKGROUND: Many epidemiological studies rely on self-reported information, the accuracy of which is critical for unbiased estimates of population health. Previously, accuracy has been analyzed by comparing self-reports to other sources, such as cancer registries. Cancer is believed to be a well-reported condition. This paper uses novel panel data to test the consistency of cancer reports for respondents with repeated self-reports. METHODS: Data come from 978 adults who reported having been diagnosed with cancer in at least one of four waves of the Panel Study of Income Dynamics, 1999-2005. Consistency of cancer occurrence reports and precision of timing of onset were studied as a function of individual and cancer-related characteristics using logistic and ordered logistic models. RESULTS: Almost 30% of respondents gave inconsistent cancer reports, meaning they said they never had cancer after having said they did have cancer in a previous interview; 50% reported the year of diagnosis with a discrepancy of two or more years. More recent cancers were reported with a higher consistency and timing precision; cervical cancer was reported more inaccurately than other cancer types. Demographic and socio-economic factors were only weak predictors of reporting quality. CONCLUSIONS: Results suggest that retrospective reports of cancer contain significant measurement error. The errors, however, are fairly random across different social groups, meaning that the results based on the data are not systematically biased by socio-economic factors. Even for health events as salient as cancer, researchers should exercise caution about the presumed accuracy of self-reports, especially if the timing of diagnosis is an important covariate.