Workplace hazards and health among informally employed domestic workers in 14 cities, United States, 2011-2012: Using four approaches to characterize workers' patterns of exposures.

BACKGROUND: We characterized informally employed US domestic workers' (DWers) exposure to patterns of workplace hazards, as well as to single hazards, and examined associations with DWers' work-related and general health. METHODS: We analyzed cross-sectional data from the sole nationwide survey of informally employed US DWers with work-related hazards data, conducted in 14 cities (2011-2012; N = 2086). We characterized DWers' exposures using four approaches: single exposures (n = 19 hazards), composite exposure to hazards selected a priori, classification trees, and latent class analysis. We used city fixed effects regression to estimate the risk ratio (RR) of work-related back injury, work-related illness, and fair-to-poor self-rated health associated with exposure as defined by each approach. RESULTS: Across all four approaches-net of individual, household, and occupational characteristics, and city fixed effects-exposure to workplace hazards was associated with increased risk of the three health outcomes. For work-related back injury, the estimated RR associated with heavy lifting (the single hazard with the largest RR), exposure to all three hazards selected a priori (worker did heavy lifting, climbed to clean, and worked long hours) versus none, exposure to the two hazards identified by classification trees (heavy lifting, verbally abused) versus "no heavy lifting," and membership in the most- versus least-exposed latent class were, respectively, 3.4 (95% confidence interval [CI] 2.7-4.1); 6.5 (95% CI 4.8-8.7); 4.4 (95% CI 3.6-5.3), and 6.6 (95% CI 4.6-9.4). CONCLUSIONS: Measures of joint work-related exposures were more strongly associated than single exposures with informally employed US DWers' health profiles.

"Registries are not only a tool for data collection, they are for action": Cancer registration and gaps in data for health equity in six population-based registries in India.

In India, population-based cancer registries (PBCRs) cover less than 15% of the urban and 1% of the rural population. Our study examines practices of registration in PBCRs in India to understand efforts to include rural populations in registries and efforts to measure social inequalities in cancer incidence. We selected a purposive sample of six PBCRs in Maharashtra, Kerala, Punjab and Mizoram and conducted semistructured interviews with staff to understand approaches and challenges to cancer registration, and the sociodemographic information collected by PBCRs. We also conducted a review of peer-reviewed literature utilizing data from PBCRs in India. Findings show that in a context of poor access to cancer diagnosis and treatment and weak death registration, PBCRs have developed additional approaches to cancer registration, including conducting village and home visits to interview cancer patients in rural areas. Challenges included PBCR funding and staff retention, abstraction of data in medical records, address verification and responding to cancer stigma and patient migration. Most PBCRs published estimates of cancer outcomes disaggregated by age, sex and geography. Data on education, marital status, mother tongue and religion were collected, but rarely reported. Two PBCRs collected information on income and occupation and none collected information on caste. Most peer-reviewed studies using PBCR data did not publish estimates of social inequalities in cancer outcomes. Results indicate that collecting and reporting sociodemographic data collected by PBCRs is feasible. Improved PBCR coverage and data will enable India's cancer prevention and control programs to be guided by data on cancer inequities.

Inequality in Place: Effects of Exposure to Neighborhood-Level Economic Inequality on Mortality.

This study contributes to the debate on whether income inequality is harmful for health by addressing several analytical weaknesses of previous studies. Using the Panel Study of Income Dynamics in combination with tract-level measures of income inequality in the United States, we estimate the effects of differential exposure to income inequality during three decades of the life course on mortality. Our study is among the first to consider the implications of income inequality within U.S. tracts for mortality using longitudinal and individual-level data. In addition, we improve upon prior work by accounting for the dynamic relationship between local areas and individuals' health, using marginal structural models to account for changes in exposure to local income inequality. In contrast to other studies that found no significant relation between income inequality and mortality, we find that recent exposure to higher local inequality predicts higher relative risk of mortality among individuals at ages 45 or older.

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.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

How social policy contributes to the distribution of population health: the case of gender health equity.

AIMS: In this study we aimed to analyze gender health equity as a case of how social policy contributes to population health. We analyzed three sets of social-investment policies implemented in Europe and previously hypothesized to reduce gender inequity in labor market outcomes: childcare; active labor market programs; and long-term care. METHODS: We use 12 indicators of social-investment policies from the OECD Social Expenditure Database, the OECD Family Database, and the Social Policy Indicators' Parental Leave Benefit Dataset. We draw outcome data from the 2015 Global Burden of Disease for years lived with disability and all-cause mortality among men and women ages 25-54 for 18 European nations over the 1995-2010 period. We estimate 12 linear regression models each for mortality and morbidity (i.e. years lived with disability), one per social-investment indicator. All models use country fixed-effects and cluster-robust standard errors. RESULTS: For years lived with disability, women benefit more from social investment for most indicators. The only exception is the percentage of young children in publicly funded childcare or schooling, which equally benefits men. For all-cause mortality, men benefit more or equally from social investment for most indicators, while women benefit more from government spending on direct job creation through civil employment. CONCLUSIONS: Social policy contributes to the distribution of population health. Social-investment advocates argue such policies in particular enhance economic gender equity. Our results show that these polices have ambiguous effects on gender health equity and even differential improvements among men for some outcomes.

Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health.

Background: Economic crises constitute a shock to societies with potentially harmful effects to the mental health status of the population, including depressive symptoms, and existing health inequalities. Methods: With recent data from the European Social Survey (2006­14), this study investigates how the economic recession in Europe starting in 2007 has affected health inequalities in 21 European nations. Depressive feelings were measured with the CES-D eight-item depression scale. We tested for measurement invariance across different socio-economic groups. Results: Overall, depressive feelings have decreased between 2006 and 2014 except for Cyprus and Spain. Inequalities between persons whose household income depends mainly on public benefits and those who do not have decreased, while the development of depressive feelings was less favorable among the precariously employed and the inactive than among the persons employed with an unlimited work contract. There are no robust effects of the crisis measure on health inequalities. Conclusion: Negative implications for mental health (in terms of depressive feelings) have been limited to some of the most strongly affected countries, while in the majority of Europe persons have felt less depressed over the course of the recession. Health inequalities have persisted in most countries during this time with little influence of the recession. Particular attention should be paid to the mental health of the inactive and the precariously employed.

The health of European populations: introduction to the special supplement on the 2014 European Social Survey (ESS) rotating module on the social determinants of health.

This introduction summarizes the main findings of the Supplement 'Social inequalities in health and their determinants' to the European Journal of Public Health. The 16 articles that constitute this supplement use the new ESS (2014) health module data to analyze the distribution of health across European populations. Three main themes run across these articles: documentation of cross-national variation in the magnitude and patterning of health inequalities; assessment of health determinants variation across populations and in their contribution to health inequalities; and the examination of the effects of health outcomes across social groups. Social inequalities in health are investigated from an intersectional stance providing ample evidence of inequalities based on socioeconomic status (occupation, education, income), gender, age, geographical location, migrant status and their interactions. Comparison of results across these articles, which employ a wide range of health outcomes, social determinants and social stratification measures, is facilitated by a shared theoretical and analytical approach developed by the authors in this supplement.

Age at menarche: 50-year socioeconomic trends among US-born black and white women.

OBJECTIVES: We investigated 50-year US trends in age at menarche by socioeconomic position (SEP) and race/ethnicity because data are scant and contradictory. METHODS: We analyzed data by income and education for US-born non-Hispanic Black and White women aged 25 to 74 years in the National Health Examination Survey (NHES) I (1959-1962), National Health Examination and Nutrition Surveys (NHANES) I-III (1971-1994), and NHANES 1999-2008. RESULTS: In NHES I, average age at menarche among White women in the 20th (lowest) versus 80th (highest) income percentiles was 0.26 years higher (95% confidence interval [CI] = -0.09, 0.61), but by NHANES 2005-2008 it had reversed and was -0.33 years lower (95% CI = -0.54, -0.11); no socioeconomic gradients occurred among Black women. The proportion with onset at younger than 11 years increased only among women with low SEP, among Blacks and Whites (P for trend < .05), and high rates of change occurred solely among Black women (all SEP strata) and low-income White women who underwent menarche before 1960. CONCLUSIONS: Trends in US age at menarche vary by SEP and race/ethnicity in ways that pose challenges to several leading clinical, public health, and social explanations for early age at menarche and that underscore why analyses must jointly include data on race/ethnicity and socioeconomic position. Future research is needed to explain these trends.

Reproductive justice and the pace of change: socioeconomic trends in US infant death rates by legal status of abortion, 1960-1980.

US infant death rates for 1960 to 1980 declined most quickly in (1) 1970 to 1973 in states that legalized abortion in 1970, especially for infants in the lowest 3 income quintiles (annual percentage change = -11.6; 95% confidence interval = -18.7, -3.8), and (2) the mid-to-late 1960s, also in low-income quintiles, for both Black and White infants, albeit unrelated to abortion laws. These results imply that research is warranted on whether currently rising restrictions on abortions may be affecting infant mortality.

Jim Crow and premature mortality among the US Black and White population, 1960-2009: an age-period-cohort analysis.

BACKGROUND: Scant research has analyzed the health impact of abolition of Jim Crow (ie, legal racial discrimination overturned by the US 1964 Civil Rights Act). METHODS: We used hierarchical age-period-cohort models to analyze US national black and white premature mortality rates (death before 65 years of age) in 1960-2009. RESULTS: Within a context of declining US black and white premature mortality rates and a persistent 2-fold excess black risk of premature mortality in both the Jim Crow and non-Jim Crow states, analyses including random period, cohort, state, and county effects and fixed county income effects found that, within the black population, the largest Jim Crow-by-period interaction occurred in 1960-1964 (mortality rate ratio [MRR] = 1.15 [95% confidence interval = 1.09-1.22), yielding the largest overall period-specific Jim Crow effect MRR of 1.27, with no such interactions subsequently observed. Furthermore, the most elevated Jim Crow-by-cohort effects occurred for birth cohorts from 1901 through 1945 (MRR range = 1.05-1.11), translating to the largest overall cohort-specific Jim Crow effect MRRs for the 1921-1945 birth cohorts (MRR ~ 1.2), with no such interactions subsequently observed. No such interactions between Jim Crow and either period or cohort occurred among the white population. CONCLUSION: Together, the study results offer compelling evidence of the enduring impact of both Jim Crow and its abolition on premature mortality among the US black population, although insufficient to eliminate the persistent 2-fold black excess risk evident in both the Jim Crow and non-Jim Crow states from 1960 to 2009.

Recessions, job loss, and mortality among older US adults.

OBJECTIVES: We analyzed how recessions and job loss jointly shape mortality risks among older US adults. METHODS: We used data for 50 states from the Health and Retirement Study and selected individuals who were employed at ages 45 to 66 years during 1992 to 2011. We assessed whether job loss affects mortality risks, whether recessions moderate the effect of job loss on mortality, and whether individuals who do and do not experience job loss are differentially affected by recessions. RESULTS: Compared with individuals not experiencing job loss, mortality risks among individuals losing their job in a recession were strongly elevated (hazard ratio = 1.6; 95% confidence interval = 1.1, 2.3). Job loss during normal times or booms is not associated with mortality. For employed workers, we found a reduction in mortality risks if local labor market conditions were depressed, but this result was not consistent across different model specifications. CONCLUSIONS: Recessions increase mortality risks among older US adults who experience job loss. Health professionals and policymakers should target resources to this group during recessions. Future research should clarify which health conditions are affected by job loss during recessions and whether access to health care following job loss moderates this relation.

Can changes in the distributions of and associations between education and income bias temporal comparisons of health disparities? An exploration with causal graphs and simulations.

Although socioeconomic position is conceptualized by social epidemiologists as a multidimensional construct, most research on socioeconomic disparities in health uses a limited set of observable indicators (e.g., educational attainment, household income, or occupational class) and typically analyzes and reports gradients in relation to one measure at a time. Societal changes in economic structures over time, however, can lead to changes in distributions of and associations between socioeconomic indicators, as has occurred with income returns to education in the United States over the last 50 years. Consequently, temporal comparisons of socioeconomic disparities from repeated cross-sectional surveys can be affected, particularly when salient dimensions of socioeconomic position are unobserved. We discuss this phenomenon within the framework of measurement error and identify sources of variation that can make identification of socioeconomic change difficult. Using simulations, we explore the utility of the quantile, slope index of inequality, and relative distribution approaches to minimizing bias in temporal comparisons and find that these methods yield correct inferences about temporal change only under limited conditions. We contrast these approaches with the use of an imputation model when validation data for the unobserved socioeconomic indicator exist. We discuss implications for analyzing changing socioeconomic health disparities over time.

The unique impact of abolition of Jim Crow laws on reducing inequities in infant death rates and implications for choice of comparison groups in analyzing societal determinants of health.

OBJECTIVES: We explored associations between the abolition of Jim Crow laws (i.e., state laws legalizing racial discrimination overturned by the 1964 US Civil Rights Act) and birth cohort trends in infant death rates. METHODS: We analyzed 1959 to 2006 US Black and White infant death rates within and across sets of states (polities) with and without Jim Crow laws. RESULTS: Between 1965 and 1969, a unique convergence of Black infant death rates occurred across polities; in 1960 to 1964, the Black infant death rate was 1.19 times higher (95% confidence interval [CI] = 1.18, 1.20) in the Jim Crow polity than in the non-Jim Crow polity, whereas in 1970 to 1974 the rate ratio shrank to and remained at approximately 1 (with the 95% CI including 1) until 2000, when it rose to 1.10 (95% CI = 1.08, 1.12). No such convergence occurred for Black-White differences in infant death rates or for White infants. CONCLUSIONS: Our results suggest that abolition of Jim Crow laws affected US Black infant death rates and that valid analysis of societal determinants of health requires appropriate comparison groups.

Health Inequalities in Global Context.

The existence of social inequalities in health is well established. One strand of research focuses on inequalities in health within a single country. A separate and newer strand of research focuses on the relationship between inequality and average population health across countries. Despite the theorization of (presumably variable) social conditions as "fundamental causes" of disease and health, the cross-national literature has focused on average, aggregate population health as the central outcome. Controversies currently surround macro-structural determinants of overall population health such as income inequality. We advance and redirect these debates by conceptualizing inequalities in health as cross-national variables that are sensitive to social conditions. Using data from 48 World Values Survey countries, representing 74% of the world's population, we examine cross-national variation in inequalities in health. The results reveal substantial variation in health inequalities according to income, education, sex, and migrant status. While higher socioeconomic position is associated with better self-rated health around the globe, the size of the association varies across institutional context, and across dimensions of stratification. There is some evidence that education and income are more strongly associated with self-rated health than sex or migrant status.

A Novel Use of Latent Class Analysis to Identify Patterns of Workplace Hazards among Informally Employed Domestic Workers in 14 Cities, United States, 2011-2012.

INTRODUCTION: Few studies, mostly descriptive, have quantitatively analyzed the working conditions of domestic workers (DWers) informally employed by private households in the USA. These workers are explicitly or effectively excluded from numerous workplace protections, and scant data exist on their exposures or how best to categorize them. METHODS: We analyzed data from the sole nationwide survey of informally employed US DWers with work-related hazards data, conducted by the National Domestic Workers Alliance, the University of Illinois Chicago Center for Urban Economic Development, and the DataCenter in 14 US cities (2011-2012; N = 2086). We used exploratory latent class analysis to identify groups of DWers with distinct patterns of exposure to 21 self-reported economic, social, and occupational workplace hazards (e.g. pay violations, verbal abuse, heavy lifting). We then used multinomial logistic latent class regression to examine associations between workers' individual, household, and occupational characteristics and latent class membership. RESULTS: Among the 2086 DWers, mean age was 42.6 years, 97.3% were women, 56.0% Latina/o, 26.5% White, 33.2% undocumented immigrants, and 11.7% live-in. 53.5%, 32.0%, and 14.5% primarily worked doing housecleaning, child care, and adult care, respectively. 49.9% of workers reported ≥3 hazards. Latent class analysis identified four groups of DWers doing: 'Low hazard domestic work' (lowest exposure to all hazards), 'Demanding care work' (moderate exposure to pay violations [item response probability (IRP) = 0.42] and contagious illness care [IRP = 0.39]), 'Strenuous cleaning work' (high exposure to cleaning-related occupational hazards, such as climbing to clean [IRP = 0.87]), and 'Hazardous domestic work' (highest exposure to all but one hazard). Covariates were strongly associated, in many cases, with latent class membership. For example, compared to other DWers, DWers doing 'hazardous domestic work' had the largest predicted probability of being economically insecure (0.53) and living-in with their employers (0.17). CONCLUSIONS: Results indicate that informally employed US DWers experience distinct patterns of workplace hazards, and that it is informative to characterize DWers' exposures to different sets of multiple hazards using latent class analysis.

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.

New Measures of Economic Insecurity Reveal its Expansion Into EU Middle Classes and Welfare States.

Economic instability, social changes, and new social policies place economic insecurity high on the scholarly and political agenda. We contribute to these debates by proposing a new multidimensional, intertemporal measure of economic insecurity that accounts for both its multiplicity and its dynamism. First, we develop three theory-driven, multidimensional measures of economic insecurity. Principal Components Analysis validates the measure. Second, we develop a dynamic approach to insecurity, using longitudinal data and a newly revised headcount method. Third, we then use our new measures to analyze the distribution of insecurity in Europe. Our analysis shows that insecurity is widespread across Europe, even in low-inequality, encompassing welfare states. Moreover, it extends across income groups and occupational classes, reaching into the middle classes.