Estimating the effects of tobacco-21 on youth tobacco use and sales.

We examine the effect of raising the minimum legal sale age of tobacco to 21 (i.e., "T21"). We estimate difference-in-differences models using the Monitoring the Future (MTF) survey data and Nielsen Retail Scanner data from 2012 to 2019. Outcomes include cigarette and e-cigarette use and sales. We find sizable reductions in e-cigarette and cigarette use for 12th graders. T21 also reduced cigarette sales by 12.4 % and e-cigarette sales by 69.3 % in counties with the highest percent quartile of individuals under 21 years of age. In terms of mechanisms, we find that T21 increases ID checking and perceived risks of using both products.

Education and reproductive health: evidence from schooling expansion in Turkey.

We investigate the role of additional years of schooling mandated by a compulsory schooling expansion law in affecting reproductive preferences and safe reproductive health behaviors in Turkey-a middle-to-high-income country with gender inequity in education but overall high levels of safe reproductive health practices at the time of passing the law. Using a fuzzy regression discontinuity design, we find that the additional schooling improved several health behaviors. However, the effects on some outcomes commonly analyzed in the existing literature, such as contraceptive use or fertility, were either weak or insignificant. Overall, our findings complement the current literature on the marginal health benefits of schooling expansion and suggest that policymakers consider the institutional and cultural factors while evaluating the scope and potential non-educational benefits of such expansions.

Impacts of COVID-19 on mental health in the US: evidence from a national survey.

BACKGROUND: Studies have reported substantial effects of the COVID-19 pandemic on mental health, but little is known whether the impacts of COVID on individuals, such as being tested for COVID or experiencing disruptions to healthcare utilization, would affect their mental health differently. AIMS: To examine the impacts of COVID-19 on depression and anxiety disorders among US adults. METHODS: We included 8098 adults with no prior mental health problems using data from the National Health Interview Survey (2019-2020). We examined two outcomes: current depression and anxiety; and three COVID-related impact measures: ever COVID test, delayed medical care, and no medical care due to COVID. Multinomial logistic regressions were conducted. RESULTS: Delayed or no medical care were significantly associated with current depression, with adjusted relative risks (aRRs) of 2.17 (95% CI, 1.48-2.85) and 1.85 (95% CI, 1.33-2.38). All three COVID-related impact measures were significantly associated with current anxiety. The aRRs were 1.16 (95% CI, 1.01-1.32) for ever COVID test, 1.94 (95% CI, 1.64-2.24) for no medical care, and 1.90 (95% CI, 1.63-2.18) for delayed medical care. CONCLUSIONS: Individuals who were affected by COVID were more likely to experience depression or anxiety disorders. Mental health services need to prioritize these high-risk groups.

Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension.

Stigma is one of the most harmful forces affecting population health. When stigma exists in clinical settings, environments that should be pro-patient and stigma-free, stigma may become internalized and affect patients' well-being. Informed by prior stigma research and the Intergroup Contact Theory, the authors elucidate statistical relationships between patients' perceptions of clinic-based stigma and stigma's impact on health among New York City's diverse residents. The authors hypothesize that perceiving stigma in clinical settings would mediate the relationships between depression, general health, diabetes, and hypertension; they tested this through multiple logistic regressions conducted on pooled data from the New York City Community Health Survey (N = 18,596, 2016-2017). Among women, depression was associated with stigma (α = 4.07, P < 0.01), hypertension (γ = 2.31, P < 0.01), diabetes (γ = 2.18, P < 0.01), and poor general health (γ = 6.34, P < 0.01). Among men, depression was associated with stigma (α = 3.7, P < 0.01), hypertension (γ = 2.35, P < 0.01), diabetes (γ = 1.86, P < 0.01), and poor general health (γ = 5.14, P < 0.01). Overall, perceived stigma in clinics significantly increased adjusted odds of self-reporting poor general health (adjusted ORs [AOR] = 1.87 men; AOR = 2.05 women). Findings contribute to the literature on the Intergroup Contact Theory, which suggests that stigma should be low in diverse communities; findings indicate that stigma may be a mediator, justifying inclusion in epidemiological and health services research. In addition, study outcomes suggest that depression may be associated with clinic-based stigma, and this stigma has deleterious effects on physical health. Thus, clinicians should emphasize stigma reduction in their facilities, potentially through the adoption of trauma-informed approaches or delivery of care using non-stigmatizing communication strategies, such as Motivational Interviewing.

Pre-existing Economic Conditions and COVID-19 Infections and Mortality in New York City.

Objectives . We investigated the association of pre-existing economic variables with COVID-19 infections and mortality in New York City. Methods . We combined ZIP code-level data from New York City's Department of Health with five-year American Community Survey data. We estimated ordinary least squares models of the prevalence of positive COVID-19 test results and deaths per 100,000 population. Results . We found ZIP codes with higher concentrations of residents living in crowded living quarters, employees in high-risk occupations, and employees commuting more than half an hour were positively and significantly associated with higher infection rates. Higher rates of crowded housing were also significantly and positively related to mortality rates, though the positive point estimates for the other two economic variables were not statistically significant. Conclusions . Economic factors such as working and living conditions beyond common measures such as poverty generate significant public health effects. Policymakers should consider these associations while designing and modifying public health policies.

Drinking during downturn: New evidence from the housing market fluctuations in the United States during the Great Recession.

We investigate how the decline in home prices over the Great Recession in the U.S. impacted drinking behavior. We match data on actual and shadow home prices (from Zillow Research) to individuals' drinking behavior from the Behavioral Risk Factor Surveillance System (BRFSS) by county of residence and year/month of the interview. We improve upon the existing literature by using new measures of exogenous macroeconomic shocks captured by fluctuations in home prices and finding heterogeneous impacts of the downturn based on homeownership. We find that decline in home prices is commonly associated with increases in alcohol consumption, both on extensive and intensive margins. Additionally, we find that the effects are more consistent among homeowners compared to renters. Given that alcohol consumption is one of the leading causes of death in the U.S. and that the COVID-19 pandemic has triggered an economic crisis in many societies, the results have important public health implications.

Impacts of insurance expansion on health cost, health access, and health behaviors: evidence from the medicaid expansion in the US.

Expansion of subsidized health insurance may result in both safer and riskier health behavior and outcomes. While having insurance lowers cost barriers to receive both usual and preventive care, the lower potential cost from adverse health events may also promote risky behavior. In this paper, I exploit expansion in the Medicaid program under the Affordable Care Act to estimate the impact of insurance expansion on health outcomes and behaviors for low-income individuals in the US. I find that expansion of coverage has significantly lowered cost and increased access, particularly among minority populations, but has had no significant impact on preventive health behaviors. At the same time, I also find no evidence of moral hazard or increase risky behavior like smoking and drinking among residents of expansion states.

The association of pregnancy control, emotions, and beliefs with pregnancy desires: A new perspective on pregnancy intentions.

CONTEXT: Standard pregnancy intentions measures do not always align with how people approach pregnancy. Studies that have investigated beyond a binary framework found that those with "ambivalent" feelings towards pregnancy are less likely to use contraception consistently, but the reasons for this are unclear. We sought to gain a nuanced understanding of pregnancy desires, and how perceptions about pregnancy are associated with contraceptive use. METHODS: We used non-probability quota sampling based on sex, age, and geographic region for a web-based survey of heterosexual men and women, aged 21-44 years, who could become pregnant/impregnate and were not currently pregnant (n = 1,477; 51% female). The survey was created using unique items informed by recent literature. Bivariate and multivariable analyses explored relationships between various perceptions about pregnancy with pregnancy desires categorized as: wanting a pregnancy, not wanting a pregnancy, and not trying but would be okay with a pregnancy. We conducted a sub-group analysis of those who were not trying but would be okay with a pregnancy (n = 460), using descriptive statistics to examine how consistent contraceptive use was associated with emotions and beliefs about avoiding pregnancy. RESULTS: After adjustment, those who felt that pregnancy may not always be avoidable, but instead determined by fate/higher power, or a natural process that happens when it is meant to, were significantly more likely (aOR: 1.83, 95% CI: 1.05-3.36; aOR: 2.21, 95% CI: 1.29-3.76, respectively) to report not trying but being okay with pregnancy, whereas those with negative feelings about a pregnancy were less likely to feel okay about a pregnancy (aOR: 0.11, 95% CI: 0.08-0.15), versus not wanting a pregnancy. In the sub-group analysis, those who felt pregnancy was determined by fate/higher power or a natural process were more likely to report not using contraception consistently (70%, 68%, respectively). CONCLUSIONS: Those who state they are not trying but would be okay with pregnancy may not use contraception consistently because of beliefs that pregnancy is predetermined. Our findings support less categorical and more multidimensional approaches to measuring fertility intentions, with important implications for reproductive health service provision.

Beyond race: Impacts of non-racial perceived discrimination on health access and outcomes in New York City.

BACKGROUND: I investigate the association of perceived discrimination based both on race and other attributes such as age, gender, and insurance status on self-reported health access and health outcomes in a diverse and densely populated metropolitan area. METHODS: Restricted data from the 2016 round of the New York City Community Health Survey was used to create prevalence estimates for both racial and non-racial discrimination. Logistic regression models were used to estimate the association of these discrimination measures with health access and health outcome variables. RESULTS: Among residents who perceived discrimination receiving health care during the previous year, 15% reported the reason behind such discrimination to race, while the rest chose other reasons. Among the non-race based categories, 34% reported the reason behind such discrimination to be insurance status, followed by other reasons (26.83%) and income (11.76%). Non-racial discrimination was significantly associated with the adjusted odds of not receiving care when needed (AOR = 6.96; CI: [5.00 9.70]), and seeking informal care (AOR = 2.24; CI: [1.13 4.48] respectively, after adjusting for insurance status, age, gender, marital status, race/ethnicity, nativity, and poverty. It was also associated with higher adjusted odds of reporting poor health (AOR = 2.49; CI: [1.65 3.75]) and being diagnosed with hypertension (AOR = 1.75; CI: [1.21 2.52]), and diabetes (AOR = 1.84; CI: [1.22 2.77]) respectively. CONCLUSIONS: Perceived discrimination in health care exists in multiple forms. Non-racial discrimination was strongly associated with worse health access and outcomes, and such experiences may contribute to health disparities between different socioeconomic groups.

Cash-based maternal health interventions can improve childhood vaccination-Evidence from India.

Childhood vaccination has lagged in countries like India, despite its demonstrated positive effects on health outcomes like infant mortality. At the same time, many conditional cash transfer programs have been effective in improving health outcomes. We estimate the effect of the world's largest maternal health program, Janani Suraksha Yojana (JSY, maternal protection scheme), on childhood vaccination in India. We exploit exogenous variations in the expansion of the policy around the country and the fact that some key vaccines are given at or near birth to identify the effects of cash-based maternal health policy on infant immunization. We find that JSY increased the probability of Bacillus Calmette-Guérin (BCG) and diphtheria, pertussis, and tetanus toxoid (DPT) vaccination among newborns and infants. However, we find almost no significant effects on the measles vaccine, which is administered several months after birth.

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color?

OBJECTIVES: Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes. METHODS: We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status. RESULTS: Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08). CONCLUSIONS: We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Perceived Stigma in Health Care Settings and the Physical and Mental Health of People of Color in the United States.

Purpose: Addressing perceived and enacted stigma in clinical settings is critical to ensuring delivery of high-quality patient-centered care, reducing health disparities, and improving population health outcomes. Methods: Data from the Behavioral Risk Factor Surveillance System's (2012-2014) Reaction to Race module were analyzed to test the hypothesis that perceived stigma in health care settings would be associated with poorer physical and mental health. Poor health was measured by (1) the number of days the respondent was physically or mentally ill over the past month and (2) depressive disorder diagnosis. Multivariate linear and logistic regression models were employed. Results: Effects of stigma on physical and mental health were significant. Perceived stigma was associated with additional 2.79 poor physical health days (ß=2.79, confidence interval [CI]=1.84-3.75) and 2.92 more days of poor mental health (ß=2.92, CI=1.97-3.86). Moreover, perceived stigma in health care settings was associated with 61% higher odds of reporting a depressive disorder (adjusted odds ratio=1.61, CI=1.29-2.00). Among other findings, individuals who were married, younger, had higher income, had college degrees, and were employed reported significantly fewer poor physical and mental health days and had lower odds of self-reported depressive disorder. Conclusions: Reducing stigma against people of color in health care settings (environments that should be pro-patient) must be a top priority for population health scholars and clinicians. Reducing perceived stigma in clinical settings may produce better mental and physical health outcomes in minority patients thereby reducing health disparities. In addition, fewer days lost to poor health could positively influence the health care system by decreasing utilization and may improve economic productivity through increasing days of good health.

Cost Analysis of Implementing a Video-Based eHealth Intervention for HIV-Positive Gay, Bisexual, and Other Men Who Have Sex With Men.

Clinician-delivered HIV prevention interventions are common and often effective but have small reach, particularly in remote, rural, or sparsely populated areas. Electronic health (eHealth) interventions may be an efficient alternative to providing HIV prevention to geographically dispersed or traditionally hard-to-reach populations, though eHealth interventions tend to have high start-up costs. We present cost data from a video-based eHealth intervention, Sex Positive!, among 1,208 U.S. gay, bisexual, and other men who have sex with men living with HIV. Specifically, we provide estimates for the cost of the intervention, overall, and per participant based on funding amounts. The total average cost per participant was $1,021. Sensitivity analyses demonstrated that reaching more participants would greatly reduce the average cost per participant. Findings indicate that the cost per person engaged in an eHealth HIV intervention is consistent with previous studies, and that further scaling up would greatly reduce the cost while increasing reach.

Associations of intimate partner violence with screening for mental health disorders among women in urban Bangladesh.

OBJECTIVES: We examined the association between intimate partner violence (IPV) and screening for depression in Bangladesh, a country with high prevalence of IPV and lack of data, awareness and provider infrastructure for mental illness. METHODS: We used data from a representative sample of 11,202 women from the 2006 Bangladesh Urban Health Survey. Elements of social learning theory were used to examine the association. Additionally, we examined the interaction effect of experiencing IPV and justification of IPV on screening for mental health disorders. RESULTS: Results indicate that women who experienced IPV were significantly more likely to be screened for mental health disorders (AOR = 2.09; 95% CI = 1.86-2.34). However, the direction of this association is reversed for women who justify various forms of IPV to varying degrees. CONCLUSIONS: These findings reflect the importance of how women's perception of violence may influence their mental health. Our results indicate a counter-intuitive association, given that we found that women's justification of IPV is adaptive for them in terms of preventing symptoms of mental health problems and have potential to inform future public health policy and research.