State COVID-19 Policies and Drug Overdose Mortality Among Working-Age Adults in the United States, 2020.

Objectives. To identify relationships between US states' COVID-19 in-person activity limitation and economic support policies and drug overdose deaths among working-age adults in 2020. Methods. We used county-level data on 140 435 drug overdoses among adults aged 25 to 64 years during January 2019 to December 2020 from the National Vital Statistics System and data on states' COVID-19 policies from the Oxford COVID-19 Government Response Tracker to assess US trends in overdose deaths by sex in 3138 counties. Results. Policies limiting in-person activities significantly increased, whereas economic support policies significantly decreased, overdose rates. A 1-unit increase in policies restricting activities predicted a 15% average monthly increase in overdose rates for men (incident rate ratio [IRR] = 1.15; 95% confidence interval [CI] = 1.09, 1.20) and a 14% increase for women (IRR = 1.14; 95% CI = 1.09, 1.20). A 1-unit increase in economic support policies predicted a 3% average monthly decrease for men (IRR = 0.97; 95% CI = 0.95, 1.00) and a 4% decrease for women (IRR = 0.96; 95% CI = 0.93, 0.99). All states' policy combinations are predicted to have increased drug-poisoning mortality. Conclusions. The economic supports that states enacted were insufficient to fully mitigate the adverse relationship between activity limitations and drug overdoses. (Am J Public Health. Published online ahead of print May 2, 2024:e1-e9. https://doi.org/10.2105/AJPH.2024.307621).

The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population.

Repeated claims that a dwindling supply of potential caregivers is creating a crisis in care for the U.S. aging population have not been well-grounded in empirical research. Concerns about the supply of family care do not adequately recognize factors that may modify the availability and willingness of family and friends to provide care to older persons in need of assistance or the increasing heterogeneity of the older population. In this paper, we set forth a framework that places family caregiving in the context of older adults' care needs, the alternatives available to them, and the outcomes of that care. We focus on care networks, rather than individuals, and discuss the demographic and social changes that may alter the formation of care networks in the future. Last, we identify research areas to prioritize in order to better support planning efforts to care for the aging U.S. population.

U.S. States' COVID-19 physical distancing policies and working-age adult mental health outcomes.

In the early months of the COVID-19 pandemic, states enacted multiple policies to reduce in-person interactions. Scholars have speculated that these policies may have contributed to adverse mental health outcomes. This study examines potential associations between states' COVID-19 physical distancing policies and working-age (18-64) adults' self-reported mental health. Mental health outcomes (depression, anxiety, worsened mental health, and sought treatment for anxiety or depression) are from the National Wellbeing Survey collected from working-age adults in the United States (U.S.) February 1 to March 18, 2021 (N = 3,804). Data on 12 state policies are from the COVID-19 U.S. State Policy Database. Analyses included logistic regression and Bayesian group index modeling, which identified sets, or "bundles," of policies that were associated with each mental health outcome. Multiple policies (both separately and in bundles) were associated with adverse mental health outcomes, with certain policies (closures and curfews on retail and other businesses) being particularly important. A one-month increase in exposure to respective model-derived physical distancing policy bundles was associated with a 36% increase in the odds of reporting that COVID-19 worsened one's mental health (odds ratio [OR] = 1·36; 95% credible interval [CRI] = 1·01 to 1·80), a 6% increase in the odds of meeting the clinical threshold for anxiety (OR = 1·06; CRI = 0·99 to 1·16), and a 15% increase in the odds of seeking treatment for anxiety or depression (OR = 1·15; CRI = 1·02 to 1·49). To accurately understand the role of states' COVID-19 policies on mental health during the pandemic, researchers must consider how collections of policies might influence outcomes.

Social isolation and subclinical vascular pathways to cerebrovascular disease.

Social isolation and lack of social support are risk factors for cardiovascular and cerebrovascular disease (CVD). This study explored the relationship between measures of social support and subclinical measures of CVD risk. 58 healthy adults ages 18 to 85 years participated in this study. The Berkman-Syme Social Network Inventory (SNI) was used to assess social isolation, with higher scores signifying less isolation. Social support was defined using the 12-Item Interpersonal Support Evaluation List (ISEL-12) with a higher score signifying higher social support. Subclinical CVD measures included carotid-femoral pulse wave velocity (cfPWV), carotid beta-stiffness index, and middle cerebral artery (MCA) pulsatility index. Path analysis models for both the SNI and ISEL appraisal domain predicting cfPWV and cerebrovascular pulsatility fit the data well. Path analyses showed significant direct paths from the SNI (ß = -.363, t = -2.91) and ISEL appraisal domain (ß = -.264, t = -2.05) to cfPWV. From cfPWV, both models revealed significant direct paths to carotid stiffness (ß = .488, t = 4.18) to carotid pulse pressure (ß = .311, t = 2.45) to MCA pulsatility (ß = .527, t = 4.64). Social isolation and appraisal of social support are related to unfavorably higher aortic stiffness, with subsequent detrimental effects on cerebrovascular hemodynamic pulsatility.

State policies that promote, and that inhibit, improved public health: An exploratory analysis of paid sick leave.

The United States has no national requirement that employers provide paid sick leave (PSL) to their employees, despite the many established public health benefits of PSL access. Many states, and some localities, have passed laws requiring PSL within their jurisdictions. Past studies have shown that these PSL mandates are effective in promoting increased PSL access. However, past studies have not considered two other commonly-used state policy initiatives-PSL preemption and right-to-work laws-that could hypothetically influence employers' decisions to provide PSL. During the past few decades, all possible combinations of these policy interventions can be found in one or more U.S. states. This study estimates the combined associations of these 3 policies with PSL access. The estimates support recent research on the positive effects of PSL mandates, but also suggest that PSL preemption and right-to-work laws may have offsetting effects. Failure to take account of these additional policies may lead to an over-estimate of the effectiveness of PSL mandates.

U.S. State Preemption Laws and Working-Age Mortality.

INTRODUCTION: The goal of this study was to estimate how state preemption laws that prohibit local authority to raise the minimum wage or mandate paid sick leave have contributed to working-age mortality from suicide, homicide, drug overdose, alcohol poisoning, and transport accidents. METHODS: County-by-quarter death counts by cause and sex for 1999-2019 were regressed on minimum wage levels and hours of paid sick-leave requirements, controlling for time-varying covariates and place- and time-specific fixed effects. The model coefficients were then used to predict expected reductions in mortality if the preemption laws were repealed. Analyses were conducted during January 2022-April 2022. RESULTS: Paid sick-leave requirements were associated with lower mortality. These associations were statistically significant for suicide and homicide deaths among men and for homicide and alcohol-related deaths among women. Mortality may decline by more than 5% in large central metropolitan counties currently constrained by preemption laws if they were able to mandate a 40-hour annual paid sick-leave requirement. CONCLUSIONS: State legislatures' preemption of local authority to enact health-promoting legislation may be contributing to the worrisome trends in external causes of death.

Effects of US state preemption laws on infant mortality.

Studies show that raising the minimum wage in a US state above the federal minimum wage can reduce infant mortality rates in those states. Some states have raised their minimum wage in recent decades, while many others did not, and have prohibited local authorities from doing so by enacting preemption laws. This study investigates how the recent emergence of state preemption laws that remove local authority to raise the minimum wage has affected infant mortality rates. Using county- and state- level data spanning 2001 through 2018, this study models infant mortality rates as a function of minimum wage levels, controlling for confounders. The estimated model, combined with information on the timing, location, and level of preempted minimum wages, is then used to estimate the number of infant deaths that occurred in 2018 that could be attributed to state preemption of local minimum wage increases. In the 9 largest (pop. > 250,000) metro counties most directly affected by state preemption, we estimate that in 2018, 25 infant deaths were attributable to preemption. This equates to a 5.4% reduction in these counties' infant mortality rate. When considering all large metro counties in preemption states, as many as 605 infant deaths could be attributed to preemption. State preemption laws that remove local authority to enact health-promoting legislation, such as minimum wage increases, are a significant threat to population health. The growing tide of these laws, particularly since 2010, may be contributing to recent troubling trends in US life expectancy.

Division of Parent Care Among Adult Children.

OBJECTIVES: Many older adults rely on their children's support to sustain community residence. Although filial norms encourage adult children to help their parents, not every child provides parent care in times of need. The majority of prior studies have adopted an individualistic perspective to examine factors associated with individual children's caregiving behavior. This study complements previous work by using the family systems perspective to understand how caregiving responsibilities are allocated among children in the family and how the pattern of care division evolves over time. METHOD: Data came from seven rounds of the National Health and Aging Trends Study (2011-2017), in which community-dwelling respondents were asked about all of their children and which children provided them with care. Multilevel models were estimated to examine how caregiving responsibilities were distributed among children and how the children's caregiving efforts responded to changes in their parents' frailty. RESULTS: About three quarters of older adults reported receiving help from only one child, and the average of monthly care hours was about 50 at baseline. As parents' frailty increased, the proportion of children providing parents rose and the allocation of parent-care hours became more equal. DISCUSSION: This study underscores the importance of using the family systems perspective to better understand adult children's caregiving behavior. Although just one adult child providing care is the most common caregiving arrangement initially, adult children tend to work with their siblings to support parents' aging in place as parents' need for care increases.

A role for genes in the 'caregiver stress process'?

The stress that accompanies caring for one's parent, and the contribution of that stress to adverse physical and mental-health outcomes, is extensively studied and widely acknowledged. Yet there has been almost no attempt to incorporate the well-documented role of genetic variation in psychological distress into research on caregiving. We use phenotypic data from a large, population-based sample linked to extensive genotype data to develop a polygenic risk score (PRS) for depression, and test for both direct and interactive effects of the PRS in a multilevel repeat-measures model of caregiver-related stress. We distinguish three groups: potential caregivers (those with a living parent who does not need care), noncaregivers (those who do not provide care to their parent that needs care), and caregivers. We also obtain separate estimates according to the gender of both the parent and child. We found that a parent's need for care, and the child's provision of care, are associated with depression in some but not all cases; in contrast the PRS was significantly associated with the risk for increased depressive symptoms (with P ≤ 0.01) in all cases. These findings support an additive genetic contribution to the diathesis-stress model of depression in the context of caregiving.

Does Paid Family Leave Reduce Nursing Home Use? The California Experience.

The intent of Paid Family Leave (PFL) is to make it financially easier for individuals to take time off from paid work to care for children and seriously ill family members. Given the linkages between care provided by family members and the usage of paid services, we examine whether California's PFL program influenced nursing home utilization in California during the 1999 to 2008 period. This is the first empirical study to examine the effects of PFL on long-term care patterns. Multivariate difference-indifference estimates across alternative comparison groups provide consistent evidence that the implementation of PFL reduced the proportion of the elderly population in nursing homes by 0.5 to 0.7 percentage points. Our preferred estimate, employing an empirically-matched group of control states, finds that PFL reduced nursing home usage by about 0.65 percentage points. For California, this represents an 11 percent relative decline in elderly nursing home utilization.

Estimating the Prevalence of Serious Mental Illness and Dementia Diagnoses Among Medicare Beneficiaries in the Health and Retirement Study.

OBJECTIVE: To estimate the prevalence of serious mental illness and dementia among Medicare beneficiaries in the Health and Retirement Study (HRS). METHODS: This study utilizes HRS-linked Medicare claims data sets and inverse probability weighting to estimate overall and age-specific cumulative prevalence rates of dementia and serious mental illnesses among 18,740 Medicare beneficiaries. Two-way tabulations determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, and binary logistic regressions determine conditional probabilities of dementia diagnoses among beneficiaries diagnosed with specific mental illnesses, controlling for covariates. RESULTS: Weighted prevalence estimates for dementia, schizophrenia (SZP), bipolar disorder (BPD), and major depressive disorder (MDD) are similar to previous studies. Odds of dementia diagnosis are significantly greater for beneficiaries diagnosed with SZP, BPD, or MDD. CONCLUSIONS: Co-occurring mental disabilities require further investigation, as in the near future increasing numbers of mentally ill older adults will need appropriate and affordable community-based services and supports.

Do U.S. states' socioeconomic and policy contexts shape adult disability?

Growing disparities in adult mortality across U.S. states point to the importance of assessing disparities in other domains of health. Here, we estimate state-level differences in disability, and draw on the WHO socio-ecological framework to assess the role of ecological factors in explaining these differences. Our study is based on data from 5.5 million adults aged 25-94 years in the 2010-2014 waves of the American Community Survey. Disability is defined as difficulty with mobility, independent living, self-care, vision, hearing, or cognition. We first provide estimates of age-standardized and age-specific disability prevalence by state. We then estimate multilevel models to assess how states' socioeconomic and policy contexts shape the probability of having a disability. Age-standardized disability prevalence differs markedly by state, from 12.9% in North Dakota and Minnesota to 23.5% in West Virginia. Disability was lower in states with stronger economic output, more income equality, longer histories of tax credits for low-income workers, and higher cigarette taxes (for middle-age women), net of individuals' socio-demographic characteristics. States' socioeconomic and policy contexts appear particularly important for older adults. Findings underscore the importance of socio-ecological influences on disability.

Disability Measurement in the Health and Retirement Study.

The Health and Retirement Study (HRS) has provided extensive and detailed national data on disability since it began in 1992, and has been used extensively in studies of disability trends and trajectories. We summarize conceptual frameworks used to characterize disability and review the HRS measures of functioning, work disability, and employer accommodations. HRS survey questions have experienced changes in wording, skip logic, or other design features over the life of the study, and we comment on the analytic challenges posed by those changes. Among our conclusions are (1) work disability and benefit eligibility are important concepts that should be considered for redesign to better reflect current concepts and policy issues; (2) methodological studies of changes in wording or skip logic should be undertaken; and (3) minor additions to survey content in areas such as temporal reference periods or changes in social-participation activities would improve measurement.

Disability-Free Life Expectancy Over 30 Years: A Growing Female Disadvantage in the US Population.

OBJECTIVES: To examine changes in active life expectancy in the United States over 30 years for older men and women (aged ≥ 65 years). METHODS: We used the 1982 and 2004 National Long Term Care Survey and the 2011 National Health and Aging Trends Study to estimate age-specific mortality and disability rates, the overall chances of survival and of surviving without disability, and years of active life for men and women. RESULTS: For older men, longevity has increased, disability has been postponed to older ages, disability prevalence has fallen, and the percentage of remaining life spent active has increased. However, for older women, small longevity increases have been accompanied by even smaller postponements in disability, a reversal of a downward trend in moderate disability, and stagnation of active life as a percentage of life expectancy. As a consequence, older women no longer live more active years than men, despite their longer lives. CONCLUSIONS: Neither a compression nor expansion of late-life disability is inevitable. Public health measures directed at older women to postpone disability may be needed to offset impending long-term care pressures related to population aging.

Disability Trajectories at the End of Life: A "Countdown" Model.

OBJECTIVES: Studies of late-life disablement typically address the role of advancing age as a factor in developing disability, and in some cases have pointed out the importance of time to death (TTD) in understanding changes in functioning. However, few studies have addressed both factors simultaneously, and none have dealt satisfactorily with the problem of missing data on TTD in panel studies. METHODS: We fit latent-class trajectory models of disablement using data from the Health and Retirement Study. Among survivors (~20% of the sample), TTD is unknown, producing a missing-data problem. We use an auxiliary regression equation to impute TTD and employ multiple imputation techniques to obtain final parameter estimates and standard errors. RESULTS: Our best-fitting model has 3 latent classes. In all 3 classes, the probability of having a disability increases with nearness to death; however, in only 2 of the 3 classes is age associated with disability. We find gender, race, and educational differences in class-membership probabilities. DISCUSSION: The model reveals a complex pattern of age- and time-dependent heterogeneity in late-life disablement. The techniques developed here could be applied to other phenomena known to depend on TTD, such as cognitive change, weight loss, and health care spending.

Parental disability, parent care, and offspring mental health outcomes.

Decades of research supports a widely held view that providing parent care is stressful, and that these stresses are associated with adverse mental health outcomes. However, some recent studies suggest an additional possibility, namely that "noncaregiver stress"-a consequence of having a parent with major care needs, but not being an active caregiver-may be a serious problem as well. This finding emerges in data which permit separate controls for parental needs for care and offspring provision of parent care. We extend these results using Generations and Gender Programme data from five countries-Bulgaria, France, Georgia, Romania, and Russia-for which the necessary variables can be comparably measured. Our outcome variable is a depression score based on a 7-item scale. In country-specific regressions, we find two instances of statistically significant associations of depression with the regular provision of personal care to a parent with care needs, i.e., the usual "caregiver stress" result. However, we also find two instances of statistically significant differences in respondents' depressive symptoms that are associated with having a parent with care needs, i.e., instances of "noncaregiver stress." We find limited evidence of gender-specific responses to both forms of stress. Our evidence supports both the typical caregiver stress response and the less-studied noncaregiver stress response, which suggests the need for additional research.

Getting help from others: the effects of demand and supply.

OBJECTIVES: This article investigates whether the help with care needs that is received from others depends on the potential supply of family helpers. METHODS: Data from the first round of survey data collected in the National Health and Aging Trends Study are used to create measures of whether help is received, the number of helpers, and the hours of help received. Regression analysis is used to relate these outcomes to indicators of the demand for and supply of helpers. RESULTS: Analyses suggest limited evidence that the receipt of help is a supply-driven phenomenon. Although the measures of child-caregiver supply are not associated with a binary indicator of help received, caregiver-supply factors are associated with the number of helpers and the total hours of help received. DISCUSSION: Findings on the total number of helpers and total hours of care have implications for the division of care labor within families and between families and nonfamily members. Foreseeable trends in the demand for and the supply of help suggest further evolution in patterns of elders' receipt of help with care needs. Even if those with needs for care continue to have their needs addressed by one or more helpers, the number of helpers, and the aggregate amount of help they provide, is likely to undergo adjustment in response to changing family patterns.

Is there a trade-off between parent care and self-care?

Caregiving for family members is often described as a 36-hour day. Previous literature has suggested that family caregivers have little time to attend to their own health needs, such as participating in leisure-time physical activity. Using data from the Health and Retirement Study, we analyze whether time-allocation decisions reflect a conflict between time devoted to informal care and time devoted to self-health promotion through physical activity. The empirical model is a system of four correlated equations, wherein the dependent variables are hours spent caregiving, frequency of moderate and vigorous physical activity, and hours spent in paid work. Results from joint estimation of the four equations indicate limited evidence of a competition between time spent in caregiving and frequency of physical activity. Parental factors that increase allocation of care time to parents do not comprehensively induce reductions in the frequency of any type of physical activity, or in hours of work, among either men or women.