Adherence to Urgent Eye Visits during the COVID-19 Pandemic: A Population Characteristics Study.

PURPOSE: To explore individual and community factors associated with adherence to physician recommended urgent eye visits via a tele-triage system during the COVID-19 pandemic. METHOD: We retrospectively reviewed acute visit requests and medical exam data between April 6, 2020 and June 6, 2020. Patient demographics and adherence to visit were examined. Census tract level community characteristics from the U.S. Census Bureau and zip code level COVID-19 related death data from the Cook County Medical Examiner's Office were appended to each geocoded patient address. Descriptive statistics, t-tests, and logistic regression analyses were performed to explore the effects of individual and community variables on adherence to visit. RESULTS: Of 229 patients recommended an urgent visit, 216 had matching criteria on chart review, and 192 (88.9%) adhered to their visit. No difference in adherence was found based on individual characteristics including: age (p = .24), gender (p = .94), race (p = .56), insurance (p = .28), nor new versus established patient status (p = .20). However, individuals who did not adhere were more likely to reside in neighborhoods with a greater proportion of Blacks (59.4% vs. 33.4%; p = .03), greater unemployment rates (17.5% vs. 10.7%; p < .01), and greater cumulative deaths from COVID-19 (56 vs. 31; p = .01). Unemployment rate continued to be statistically significant after controlling for race and cumulative deaths from COVID-19 (p = .04). CONCLUSION: We found that as community unemployment rate increases, adherence to urgent eye visits decreases, after controlling for relevant neighborhood characteristics. Unemployment rates were highest in predominantly Black neighborhoods early in the pandemic, which may have contributed to existing racial disparities in eye care.

L'associazione tra fumo di tabacco e crisi economiche in Italia.

OBJECTIVES: to analyse the association between smoking behaviour and economic crises in Italy between 1993 and 2015. DESIGN: ecological study, carried out on data of the Italian National Institute of Statistics, by means of fixed-effect panel regressions. SETTING AND PARTICIPANTS: the rate of smoking prevalence (disaggregated by gender and age) and the unemployment rate (disaggregated by gender and referring to individuals aged 15 or more) were collected for each of the twenty Italian regions. Also, percentage fluctuations of the national real gross domestic product (GDP) were collected to identify the years of severe economic crisis. MAIN OUTCOME MEASURES: number of people who smoke per 100 people with the same features. RESULTS: among men, increased regional unemployment rate was associated with increased smoking behaviour only in the group aged 25-34 years. Differently, severe economic crises were associated with increased smoking in almost all age groups, except for men aged 15-24 years. A 1-point decrease in GDP was associated with 0.75 more smokers aged 15 years or more. The highest coefficient was reported among men aged 35-44 years, where a 1-point decrease in GDP was associated with 1.16 more smokers (every 100 men). This age group is also featured by the second highest prevalence of tobacco smoking (36.8%). Among women, a 1-point increase in the regional unemployment rate was associated with 0.08 less smokers every 100 women. Similarly, periods of severe economic crisis at national level were associated with reduced smoking behaviour among women aged 15 years or more, specifically those aged 15-24 years. Differently, women aged 25-34 and 65 years or more showed an association similar to that reported among men. In these groups, a 1-point decrease in GDP was associated with 0.67 and 1.08 more smokers every 100 women. While among the latter the prevalence of tobacco smoking is the lowest, among the former it is the third highest prevalence (21.69%). Therefore, increased smoking behaviour due to economic crises seems to occur especially among women aged 25-35 years old, as happens among men. CONCLUSIONS: men in almost all age groups and women aged 25-34 and 65 years or more represent vulnerable groups in which smoking behaviour may increase in times of economic hardship. Therefore, specific policies should be implemented to prevent this occurrence, as well as the negative health outcomes of tobacco smoking.

Breast Cancer-Related Employment Disruption and Financial Hardship in the Sister Study.

Background: More than one-half of breast cancer cases are diagnosed among women aged younger than 62 years, which may result in employment challenges. This study examined whether cancer-related employment disruption was associated with increased financial hardship in a national US study of women with breast cancer. Methods: Women with breast cancer who were enrolled in the Sister or Two Sister Studies completed a survivorship survey in 2012. Employment disruption was defined as stopping work completely or working fewer hours after diagnosis. Financial hardship was defined as: 1) experiencing financial problems paying for cancer care, 2) borrowing money or incurring debt, or 3) filing for bankruptcy because of cancer. Prevalence ratios and 95% confidence intervals for the association between employment disruption and financial hardship were estimated using multivariable Poisson regression with robust variance. Results: We analyzed data from women employed at diagnosis (n = 1628). Women were a median age of 48 years at diagnosis and 5.6 years from diagnosis at survey completion. Overall, 27.3% of women reported employment disruption (15.4% stopped working; 11.9% reduced hours), and 21.0% experienced financial hardship (16.0% had difficulty paying for care; 12.6% borrowed money or incurred debt; 1.8% filed for bankruptcy). In adjusted analysis, employment disruption was associated with nearly twice the prevalence of financial hardship (prevalence ratio = 1.93, 95% confidence interval = 1.58 to 2.35). Conclusions: Women experiencing employment disruptions after breast cancer may be more vulnerable to financial hardship. Findings highlight the need to target risk factors for employment disruption, facilitate return to work or ongoing employment, and mitigate financial consequences after cancer.

Determinantes sociales de la salud asociados a la severidad y mortalidad en pacientes con COVID-19 / Social determinants of health associated with severity and mortality in patients with COVID-19

Resumen Introducción: Históricamente, las pandemias han tenido como resultado tasas de mortalidad más altas en las poblaciones más vulnerables. Los determinantes sociales de la salud (DSS) se han asociado a la morbimortalidad de las personas en diferentes niveles. Objetivo: Determinar la relación entre los DSS, la severidad de COVID-19 y la mortalidad por esta enfermedad. Métodos: Estudio retrospectivo en el que se recolectaron datos de pacientes con COVID-19 en un hospital público de Chile. Las variables sociodemográficas relacionadas con los DSS estructurales se clasificaron según las siguientes categorías: sexo, edad (< 65 años, ≥ 65 años), educación secundaria (completada o no), condición de trabajo (activo, inactivo) e ingreso económico (< USD 320, ≥ USD 320). Resultados: Fueron incluidos 1012 casos con COVID-19 confirmados por laboratorio. La edad promedio fue de 64.2 ± 17.5 años. La mortalidad de la muestra total fue de 14.5 %. La edad, nivel educativo, desempleo e ingresos tuvieron fuerte asociación con la mortalidad (p < 0.001). Conclusiones: Los hallazgos refuerzan la idea de que los DSS deben considerarse una prioridad de salud pública, por lo que los esfuerzos políticos deben centrarse en reducir las desigualdades en salud para las generaciones futuras.

Abstract Introduction: Historically, pandemics have resulted in higher mortality rates in the most vulnerable populations. Social determinants of health (SDH) have been associated with people morbidity and mortality at different levels. Objective: To determine the relationship between SDH and COVID-19 severity and mortality. Methods: Retrospective study, where data from patients with COVID-19 were collected at a public hospital in Chile. Sociodemographic variables related to structural SDH were classified according to the following categories: gender, age (< 65 years, ≥ 65 years), secondary education (completed or not), work status (active, inactive) and income (< USD 320, ≥ USD 320). Results: A total of 1,012 laboratory-confirmed COVID-19 cases were included. Average age was 64.2 ± 17.5 years. Mortality of the entire sample was 14.5 %. Age, level of education, unemployment and income had a strong association with mortality (p < 0.001). Conclusions: The findings reinforce the idea that SDH should be considered a public health priority, which is why political efforts should focus on reducing health inequalities for future generations.

Income loss after a cancer diagnosis in Germany: An analysis based on the socio-economic panel survey.

BACKGROUND AND AIMS: Cancer treatments often require intensive use of healthcare services and limit patients' ability to work, potentially causing them to become financially vulnerable. The present study is the first attempt to measure, on the German national level, the magnitude of absolute income loss after a cancer diagnosis. METHODS: This study analyzes data from the Socio-Economic Panel (SOEP) survey, one of the largest and most comprehensive household surveys in Germany, consisting of approximately 20,000 individuals, who are traced annually. The empirical strategy consists of ordinary least squares (OLS) and multinomial logistic estimators to measure changes in job income, work status, working hours, and pension as a result of reporting a cancer diagnosis for the period between 2009 and 2015. Sample consistency checks were conducted to limit measurement error biases. RESULTS: Our results show that job incomes dropped between 26% and 28% within the year a cancer diagnosis was reported. The effect persisted for two years after the diagnosis and was no longer observable after four years. The finding was linked to an increased likelihood of unemployment and a reduction of working hours by 24%. Pension levels, on the other hand, were not affected by a cancer diagnosis. CONCLUSIONS: These findings suggest that many cancer patients are exposed to financial hardship in Germany, particularly when the cancer diagnosis occurs during their working age and before requirements to obtain a pension are met. Further research seems warranted to identify particularly vulnerable patient groups.

Risk factors for return to work in colorectal cancer survivors.

BACKGROUND: The increasing incidence of colorectal cancer among individuals in the productive age-group has adversely affected the labor force and increased healthcare expenses in recent years. Return to work (RTW) is an important issue for these patients. In this study, we explored the factors that influence RTW and investigated the influence of RTW on survival outcomes of patients with colorectal cancer. METHODS: Data of individuals (N = 4408) in active employment who were diagnosed with colorectal cancer between 2004 and 2010 were derived from 2 nationwide databases. Subjects were categorized into 2 groups according to their employment status at 5-year follow-up. Logistic regression analysis was performed to identify the factors associated with RTW. Survivors were further followed up for another 8 years. Propensity score matching was applied to ensure comparability between the two groups, and survival analysis was performed using the Kaplan-Meier method. RESULTS: In multivariable regression analysis for 5-year RTW with different characteristics, older age (OR: 0.57 [95% CI, 0.48-0.69]; p < 0.001), treatment with radiotherapy (OR: 0.69 [95% CI, 0.57-0.83]; p < 0.001), higher income (OR: 0.39 [95% CI, 0.32-0.47]; p < 0.001), medium company size (OR: 0.78 [95% CI, 0.63-0.97]; p = 0.022), and advanced pathological staging (stage I, OR: 16.20 [95% CI, 12.48-21.03]; stage II, OR: 13.12 [95% CI, 10.43-16.50]; stage III, OR: 7.68 [95% CI, 6.17-9.56]; p < 0.001 for all) revealed negative correlations with RTW. In Cox proportional hazard regression for RTW and all-cause mortality, HR was 1.11 (95% CI, 0.80-1.54; p = 0.543) in fully adjusted model. CONCLUSION: Older age, treatment with radiotherapy, higher income, medium company size, and advanced pathological stage showed negative correlations with RTW. However, we observed no significant association between employment and all-cause mortality. Further studies should include participants from different countries, ethnic groups, and patients with other cancers.

Using graphic modelling to identify modifiable mediators of the association between area-based deprivation at birth and offspring unemployment.

BACKGROUND: Deprivation can perpetuate across generations; however, the causative pathways are not well understood. Directed acyclic graphs (DAG) with mediation analysis can help elucidate and quantify complex pathways in order to identify modifiable factors at which to target interventions. METHODS AND FINDINGS: We linked ten Scotland-wide databases (six health and four education) to produce a cohort of 217,226 pupils who attended Scottish schools between 2009 and 2013. The DAG comprised 23 potential mediators of the association between area deprivation at birth and subsequent offspring 'not in education, employment or training' status, covering maternal, antenatal, perinatal and child health, school engagement, and educational factors. Analyses were performed using modified g-computation. Deprivation at birth was associated with a 7.3% increase in offspring 'not in education, employment or training'. The principal mediators of this association were smoking during pregnancy (natural indirect effect of 0·016, 95% CI 0·013, 0·019) and school absences (natural indirect effect of 0·021, 95% CI 0·018, 0·024), explaining 22% and 30% of the total effect respectively. The proportion of the association potentially eliminated by addressing these factors was 19% (controlled direct effect when set to non-smoker 0·058; 95% CI 0·053, 0·063) for smoking during pregnancy and 38% (controlled direct effect when set to no absences 0·043; 95% CI 0·037, 0·049) for school absences. CONCLUSIONS: Combining a DAG with mediation analysis helped disentangle a complex public health problem and quantified the modifiable factors of maternal smoking and school absence that could be targeted for intervention. This study also demonstrates the general utility of DAGs in understanding complex public health problems.

Unemployment and Health-Related Quality of Life in Melanoma Patients During the COVID-19 Pandemic.

The outbreak of coronavirus disease-2019 (COVID-19) ineluctably caused social distancing and unemployment, which may bring additional health risks for patients with cancer. To investigate the association of the pandemic-related impacts with the health-related quality of life (HRQoL) among patients with melanoma during the COVID-19 pandemic, we conducted a cross-sectional study among Chinese patients with melanoma. A self-administered online questionnaire was distributed to melanoma patients through social media. Demographic and clinical data, and pandemic-related impacts (unemployment and income loss) were collected. HRQoL was determined by the Functional Assessment of Cancer Therapy-General (FACT-G) and its disease-specific module (the melanoma subscale, MS). A total of 135 patients with melanoma completed the study. The mean age of the patients was 55.8 ± 14.2 years, 48.1% (65/135) were male, and 17.04% (34/135) were unemployed since the epidemic. Unemployment of the patients and their family members and income loss were significantly associated with a lower FACT-G score, while the MS score was associated with the unemployment of the patients' family members. Our findings suggested that unemployment is associated with impaired HRQoL in melanoma patients during the COVID-19 epidemic.

Impact of employment and insurance status on distress in gynecologic oncology patients.

OBJECTIVES: To study associations among employment, insurance status, and distress in gynecologic oncology patients; and to evaluate the impact of being unemployed or having no/Medicaid insurance on different distress problem areas. METHODS: In this single institution, cross-sectional analysis of gynecologic oncology patients, we screened for distress and problem areas using the National Comprehensive Cancer Network distress thermometer and problem list at outpatient appointments between 6/2017-9/2017. Primary outcome was self-reported high distress (score ≥ 5). The distress problem list included 5 categories-practical, family, emotional, physical, and other. Employment status included employed, unemployed, homemaker, and retired. Logistic regression was used to predict high distress from employment and insurance statuses, adjusting for relevant covariates. RESULTS: Of 885 women, 101 (11.4%) were unemployed, and 53 (6.0%) uninsured or had Medicaid coverage. One in five patients (n = 191, 21.6%) indicated high distress. Unemployed patients were more likely than employed to endorse high distress [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI) 2.2-5.7, p < 0.001]. Compared to employed patients, a greater proportion of unemployed patients endorsed distress related to practical (p < 0.05), emotional (p < 0.001), physical (p < 0.01), and other (p < 0.05) problems. Uninsured/Medicaid patients were more likely to endorse high distress (aOR = 2.8, 95% CI 1.5-5.1, p < 0.001) and report family (p < 0.001), emotional (p < 0.001), and other (p < 0.01) problems than patients who had Medicare/commercial insurance. CONCLUSIONS: Gynecologic oncology patients who are unemployed or have no/Medicaid insurance face high distress that appears to arise from issues beyond practical problems, including financial and/or insurance insecurities.

Newly diagnosed disease and job loss: a nationwide longitudinal study among middle-aged Japanese.

OBJECTIVES: Since previous studies have only used past or current medical history of disease, there is no information on newly diagnosed disease in relation to job loss. Our objective was therefore to investigate whether newly diagnosed chronic disease increased job loss among middle-aged Japanese. METHODS: We analysed data on 31 403 Japanese workers aged 50-59 years from a nationally representative longitudinal study. We defined two types of job loss; later job loss (within 1 year of disease diagnosis) and concurrent/later job loss (at around the time of diagnosis and within 1 year of diagnosis). Generalised estimating equation models were used to calculate ORs for job loss among current workers after a new-diagnosis of chronic disease (diabetes, hypertension, hyperlipidaemia, heart disease, stroke and cancer), using a discrete-time design and adjusting for demographic, socioeconomic and health behavioural factors. We used inverse probability weighting to account for non-response at follow-up. RESULTS: ORs for concurrent/later job loss were 1.17 (95% CI 1.03-1.31) for diabetes, 1.01 (95% CI 0.93-1.09) for hypertension, 1.01 (95% CI 0.94-1.09) for hyperlipidaemia, 1.21 (95% CI 1.06-1.40) for heart disease, 1.48 (95% CI 1.21-1.81) for stroke and 1.38 (95% CI 1.17-1.62) for cancer diagnosed patients. The corresponding ORs for later job loss were 1.14 (95% CI 0.96-1.35), 1.00 (95% CI 0.90-1.12), 0.98 (95% CI 0.88-1.08), 1.24 (95% CI 1.02-1.49), 1.16 (95% CI 0.86-1.55) and 1.39 (95% CI 1.11-1.73). CONCLUSIONS: New diagnosis of diabetes, heart disease, cancer and stroke increased the risk of job loss; loss was concurrent for diabetes mellitus and stroke, and concurrent/later for cancer and heart disease. Our results provide fundamental information for employment support for patients with chronic disease.

Employment disruption following the diagnosis of endometrial cancer.

BACKGROUND: Oncologic treatment has been associated with unemployment. As endometrial cancer is highly curable, it is important to assess whether patients experience employment disruption after treatment. We evaluated the frequency of employment change following endometrial cancer diagnosis and assessed factors associated with it. METHODS: A cohort of patients 18-63 years-old who were diagnosed with endometrial cancer (January 2009-December 2017) were identified in the Truven MarketScan database, an insurance claims database of commercially insured patients in the United States. All patients who were working full- or part-time at diagnosis were included and all employment changes during the year following diagnosis were identified. Clinical information, including use of chemotherapy and radiation, were identified using Common Procedural Terminology codes, and International Statistical Classification of Diseases codes. Cox proportional hazards models incorporating measured covariates were used to evaluate the impact of treatment and demographic variables on change in employment status. RESULTS: A total of 4381 women diagnosed with endometrial cancer who held a full-time or part-time job 12 months prior to diagnosis were identified. Median age at diagnosis was 55 and a minority of patients received adjuvant therapy; 7.9% received chemotherapy, 4.9% received external-beam radiation therapy, and 4.1% received chemoradiation. While most women continued to work following diagnosis, 21.7% (950) experienced a change in employment status. The majority (97.7%) of patients had a full-time job prior to diagnosis. In a multivariable analysis controlling for age, region of residence, comorbidities, insurance plan type and presence of adverse events, chemoradiation recipients were 34% more likely to experience an employment change (HR 1.34, 95% CI 1.01-1.78), compared to those who only underwent surgery. CONCLUSION: Approximately 22% of women with employer-subsidized health insurance experienced a change in employment status following the diagnosis of endometrial cancer, an often-curable disease. Chemoradiation was an independent predictor of change in employment.

Unemployment, poverty, and hunger in Brazil in Covid-19 pandemic times / Desemprego, pobreza e fome no Brasil em tempos de pandemia por Covid-19

ABSTRACT This scientific note presents preliminary developments of the Covid-19 pandemic on unemployment, poverty, and hunger in Brazil. The data on unemployment rate, un employment insurance claims, contingent of families in extreme poverty, and food insecurity was collected in government information systems, research published by public agencies, scientific articles, and in news portals. In an upward trajectory since 2015, the increase in unemployment and the number of families in extreme poverty was exacerbated after the pandemic began, drastically reducing the purchase power and access to healthy and adequate food, affecting mainly women and the populations of the Northern and Northeastern regions. Between January and September 2020, there was a 3% increase in unemployment in Brazil and, in October 2020, there were almost 485 thousand more families in extreme poverty compared to January of the same year. There are inadequate and insufficient responses from the Brazilian government to the articulated set of problems. The Covid-19 pandemic is a new element that potentiates the recent increase in hunger in Brazil, which occurs in parallel with the dismantling of the Food and Nutrition Security programs and the expansion of fiscal austerity measures, started with the political-economic crisis in 2015. There is an urgent need to recover the centrality of the agenda to fight hunger in Brazil, associated with the development of more robust contributions on the impact of the pandemic on the phenomena of poverty and hunger.

RESUMO Nesta nota científica apresentam-se desdobramentos preliminares da pandemia de Covid-19 sobre o desemprego, a pobreza e a fome no Brasil. Utilizaram-se dados sobre a taxa de desocupação, solicitações de seguro-desemprego e contingente de famílias em extrema pobreza e em insegurança alimentar, coletados em sistemas de informação governamentais, em pesquisas publicadas por órgãos públicos, em artigos científicos e em portais de notícias. Em trajetória ascendente, desde 2015, identificou-se um aumento do desemprego e do número de famílias em extrema pobreza após a instauração da pandemia, o que pode reduzir drasticamente o poder de compra e o acesso à alimentação adequada e saudável, afetando, principalmente, as mulheres e a população das regiões Norte e Nordeste. Entre janeiro e setembro de 2020, houve o aumento de 3% desemprego no Brasil e, em outubro de 2020, havia quase 485 mil famílias a mais em situação de extrema pobreza, relativamente a janeiro do mesmo ano. Verificam-se respostas inadequadas e insuficientes do governo brasileiro frente ao conjunto articulado de problemas. A pandemia de Covid-19 consiste em um novo elemento potencializador do aumento recente da fome no Brasil, que ocorre paralelamente ao desmonte dos programas de Segurança Alimentar e Nutricional e à ampliação de medidas de austeridade fiscal iniciadas com a crise político-econômica em 2015. Urge resgatar a centralidade da agenda de combate à fome no Brasil, associadamente ao desenvolvimento de contribuições mais robustas sobre o impacto da pandemia nos fenômenos da pobreza e da fome.

Evaluation of productivity losses due to premature mortality from colorectal cancer.

Cancer is responsible annually for around 27% of all deaths in Spain, 15% of which are caused by colorectal cancer. This malignancy has increased its incidence considerably over the past years, which surely impacts global productivity losses. The evaluation of lost productivity due to premature mortality provides valuable information that guides healthcare policies into the establishment of prevention and screening programs. The purpose of this study was to assess the productivity losses from premature deaths due to colorectal cancer over a ten year period (2008-2017). The costs derived from premature mortality due to this highly prevalent cancer were estimated using data on mortality, age- and sex-specific reference salaries and unemployment rates in Spain via the human capital approach. Between 2008 and 2017, 15,103 persons died per year from colorectal cancer, representing almost 15% of all cancer-related deaths. Annually, 25,333 years of potential productive life were estimated to be lost on average, 14,992 in males and 10,341 in females. Productivity losses summed €510.8 million in in 2017, and the cancers of the colon and rectum accounted for 9.6% of cancer-related productivity losses in 2017 in Spain. Colorectal cancer has an important weight in terms of productivity losses within the Spanish population, consequently, prevention and early detection programmes should be promoted and implemented to achieve significant reductions in mortality and productivity losses.

Increased unemployment from the COVID-19 pandemic, what might be the adverse impacts on cardiovascular disease in Aotearoa/New Zealand and how might this be prevented?

Despite success with eliminating the COVID-19 pandemic in Aotearoa New Zealand (at least to early August 2020), the response to the pandemic threat has resulted in a range of negative social and economic impacts, including job losses. Understanding the health consequences of these impacts will be increasingly important in the 'recovery' phase. This article contributes to this understanding by exploring the relationship between unemployment and cardiovascular disease (CVD)-a major contributor to health loss in Aotearoa New Zealand. We reviewed the literature about the impact of unemployment on CVD. The totality of the evidence suggested that increased unemployment arising from economic shocks is associated with increased CVD incidence, particularly for middle-aged men. Continued monitoring and active policy responses are required to prevent increases in CVD (and other health outcomes) as a result of the COVID-19 pandemic response. For example, quantifying the CVD-related health loss from pandemic-associated unemployment, along with the health costs and impact on health inequalities, could help with government decision-making to reduce CVD burdens. This could be via intensifying tobacco control, regulating the food supply (eg, to reduce salt/sodium levels), and improving uptake of CVD preventive medications such as statins and anti-hypertensives.

Population risk factors for COVID-19 deaths in Nigeria at sub-national level.

INTRODUCTION: Nigeria is the most populous country in the African continent. The aim of this study was to analyze risk factors for COVID-19 prevalence and deaths in all 6 geopolitical regions and 37 States in Nigeria. METHODS: we analyzed the data retrieved from various sources, including Nigeria CDC, Nigeria National Bureau of Statistics, Unicef-Nigeria multiple indicator cluster survey and the Institute of Health Metrics and Evaluation, University of Washington. We examined 4 clinical risk factors (prevalence of TB, HIV, smoking and BCG vaccination coverage) and 5 sociodemographic factors (age ≥65, population density, literacy rate, unemployment and GDP per capita). Multivariate modeling was conducted using generalized linear model. RESULTS: our analysis showed that the incidence of confirmed COVID-19 cases differed widely across the 37 States, from 0.09 per 100,000 in Kogi to 83.7 in Lagos. However, more than 70% of confirmed cases were concentrated in just 7 States: Lagos, Abuja, Oyo, Kano, Edo, Rivers and Delta. Case mortality rate (CMR) also varied considerably, with Lagos, Abuja and Edo having CMR above 9 per million population. On bivariate analysis, higher CMR correlated positively with GDP (r=0.53) and to a lesser extent with TB (r=0.36) and population density (r=0.38). On multivariate analysis, which is more definitive, States with higher HIV prevalence and BCG coverage had lower CMR, while high GDP States had a greater CMR. CONCLUSION: this study indicates that COVID-19 has disproportionately affected certain States in Nigeria. Population susceptibility factors include higher economic development but not literacy or unemployment. Death rates were mildly lower in States with higher HIV prevalence and BCG vaccination coverage.

Asymmetric behavior of tobacco consumption in Spain across the business cycle: a long-term regional analysis.

Many theoretical and empirical studies have analyzed the relationship between the economic cycle and tobacco consumption using the GDP and unemployment rates as the key variables for measuring economic phases. However, few studies focus on the pathways that cause tobacco consumption to be linked with the economic cycle, and there are no studies analyzing the heterogeneous effects underlying this relationship across nations and regions. This article explores the relationship and its pathways in 16 Spanish regions for the period 1989-2018. To this end, we apply a Granger causality analysis based on the augmented vector autoregressive (VAR) model in levels and extra lags. This method provides more efficient and robust results than the standard VAR model, which can lead to biased results with limited samples, especially in a region-by-region analysis. The empirical results suggest that the impact of the business cycle on tobacco consumption is heterogeneous and specific to each region. In addition, although recession phases cause a decline in tobacco consumption in Spain, in line with the literature, this procyclical relationship does not occur for expansion phases in all regions. One of the main findings of this article is that in expansion phases, tobacco consumption is sensitive to GDP, while in recession phases, tobacco consumption is affected by unemployment. National and regional governments should consider these results when they develop smoking control policies because homogeneous strategies can lead to heterogeneous results. Thus, the results can be useful for policymakers dealing with tobacco control strategies.

Prison sentencing increases the risk of unemployment among illegal heroin users in Taiwan.

BACKGROUND: Previous studies have rarely explored the effect of type of sentencing on employment status among illegal heroin users, therefore, we aims to examine the association of the sentencing types and employment outcomes among illegal heroin users in Taiwan. METHODS: Participants with illegal heroin use were identified through the national prison register system and deferred prosecution system: 2406 with deferred prosecutions, 4741 with observation and rehabilitation, 15 compulsory rehabilitation and 1958 sentenced to prison in calendar 2011. Logistic regression models were built to estimate the effect of sentencing type on unemployment status at 2 years after release. Stratification analysis was conducted to determine the effect of sentencing type based on the offender's employment status before sentencing. RESULTS: Illegal heroin users receiving a prison sentence were more than twice as likely to be unemployed 2 years later than those receiving deferred prosecution. The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior drug use criminal records were also higher risk of unemployment. Subgroup analysis by prior employment status revealed that being sentenced to prison, observation and rehabilitation and compulsory rehabilitation affected the subsequent employment status only for those heroin users with a job before sentencing. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment outcomes. CONCLUSIONS: Illegal heroin users who receive a prison sentence have a much higher risk of unemployment than those who receive deferred prosecution after controlling potential confounders, especially those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk of unemployment outcomes. Our study support that illegal heroin user is legally regarded as a patient before being regarded as a criminal, so giving priority to quit addition rather than imprisonment.

Education level as a predictor of survival in patients with multiple myeloma.

BACKGROUND: Disparities in multiple myeloma (MM) prognosis based on sociodemographic factors may exist. We investigated whether education level at diagnosis influenced Chinese MM patient outcomes. METHODS: We performed a multicenter retrospective analysis of data from 773 MM patients across 9 centers in China from 2006 to 2019. Sociodemographic and clinical factors at diagnosis and treatment regimens were recorded, and univariate and multivariate analyses were performed. RESULTS: Overall, 69.2% of patients had low education levels. Patients with low education levels differed from those with high education levels in that they were more likely to be older, and a higher proportion lived in rural areas, were unemployed, had lower annual incomes and lacked insurance. Additionally, compared to patients with high education levels, patients with low education levels had a higher proportion of international staging system (ISS) stage III classification and elevated lactate dehydrogenase (LDH) levels and underwent transplantation less often. Patients with high education levels had a median progression-free survival (PFS) of 67.50 (95% confidence interval (CI): 51.66-83.39) months, which was better than that of patients with low education levels (30.60 months, 95% CI: 27.38-33.82, p < 0.001). Similarly, patients with high education levels had a median overall survival (OS) of 122.27 (95% CI: 117.05-127.49) months, which was also better than that of patients with low education levels (58.83 months, 95% CI: 48.87-62.79, p < 0.001). In the multivariable analysis, patients with high education levels had lower relapse rates and higher survival rates than did those with low education level in terms of PFS and OS (hazard ratio (HR) = 0.50 [95% CI: 0.34-0.72], p < 0.001; HR = 0.32 [0.19-0.56], p < 0.001, respectively). CONCLUSIONS: Low education levels may independently predict poor survival in MM patients in China.

Association between unemployment and the co-occurrence and clustering of common risky health behaviors: Findings from the Constances cohort.

BACKGROUND: Unemployment is associated with a high prevalence of risky health behaviors. Mortality increases with the number of co-occurring risky behaviors but whether these behaviors co-occur with a greater than expected frequency (clustering) among unemployed people is not known. METHODS: Differences according to unemployment status in co-occurrence and clustering of smoking, alcohol abuse, low leisure-time physical activity and unhealthy diet (marked by low fruit and vegetable intake) were assessed in 65,630 salaried workers, aged 18 to 65, who were participants in Constances, a French population-based cohort. Among them, 4573 (7.0%) were unemployed without (n = 3160, 4.8%) or with (n = 1413, 2.1%) past experience of unemployment. RESULTS: Compared to the employed, unemployed participants without or with past experience of unemployment were similarly overexposed to each risky behavior (sex and age adjusted odds-ratios ranging from 1.38 to 2.19) except for low physical activity, resulting in higher rates of co-occurrence of two, three and four behaviors (relative risk ratios, RRR 1.20 to 3.74). Association between behavior co-occurrence and unemployment did not vary across gender, partnership status or income category. Risky behavior clustering, i.e., higher than expected co-occurrence rates based on the prevalence of each behavior, was similar across unemployment status. The same observations can be made in employed participants with past experience of unemployment, although overexposure to risky behaviors (ORs 1.15 to 1.38) and increased rates of co-occurrence (ORs 1.19 to 1.58) were not as pronounced as in the unemployed. CONCLUSIONS: Co-occurrence of risky behaviors in currently and/or formerly unemployed workers is not worsened by behavior clustering. Engagement in each of these behaviors should be considered an engagement in distinct social practices, with consequences for preventive policies.