Utilizing Consumer-Directed Care Among Older Adults: Identifying Barriers From Behavioral Economics Perspectives.

Consumer-directed Care (CDC) empowers older people to flexibly arrange services and enhances their well-being. Prior studies have suggested that limited attention and hassle costs are major demand-side barriers to using CDC. However, many other psychosocial factors were unexplored. In this study, we explore associations between CDC utilization and a wider range of psychosocial factors based on behavioral economics theories. A cross-sectional telephone survey of older persons (or family members that represent them) was conducted in Guangzhou, China in 2021. We adopted a two-stage sampling method based on administrative records and analyzed the data using multivariate logistic models. Procedural literacy, hassle costs, and social norms regarding CDC were associated with using CDC. The findings reveal nuances in the decision-making process, and people are not unboundedly rational in making care-related decisions. Policymakers could employ cost-effective tools to facilitate CDC utilization and optimize resources to address the most crucial service barriers.

Developing an Operationalized Framework for Comparing Consumer-Directed Care for Older Adults: Evidence from Expert Survey and Cross-National Comparison.

Consumer-directed care (CDC) programs for older people aim to optimize health outcomes by offering clients control and flexibility regarding service arrangements. However, policy design features may differ due to heterogenous sociostructural systems. By operationalizing a framework with three dimensions of CDC, i.e. control and direct services, variety of service options, and information and support, we analyzed how countries vary in their policy designs to achieve consumer direction. Using an expert survey (n = 20) and cross-national document analysis, we analyzed 12 CDC programs from seven selected countries: the United States, the United Kingdom, Germany, the Netherlands, China, Australia, and Spain. Among the three dimensions, CDC programs placed more emphasis on and displayed more homogenous performance of policy designs that achieve consumer direction in the dimension of control and direct services, while less emphasis was placed on and more heterogenous performance displayed in the dimensions of variety of service options and information and support. We offer a systematically operationalized framework to investigate CDC policy designs. Findings advance our understanding of CDC policy features from a cross-national perspective. Policymakers could incorporate these findings to empower older people in their respective societies.

Long-term Care Insurance and Health and Perceived Satisfaction of Older Chinese: Comparisons Between Urban/Rural Areas, Chronic Conditions, and Their Intersectionality.

BACKGROUND: Evidence of the impact of long-term care insurance (LTCI) on health and well-being has predominantly come from developed countries. China officially launched its city-level LTCI policy in 2016. Recent evidence in China has shown that having an LTCI program contributes to positive health. However, it is unclear whether such positive policy effects were attributed to policy announcement or implementation effects, and whether the policy effects vary by locality, chronic conditions, and their intersectionality. This study examines whether there are longitudinal health benefits for older Chinese who are participating in LTCI, particularly considering their city location (urban/rural), whether they have chronic conditions, and the intersectionality. METHODS: Following the Andersen Behavioral Model, health and satisfaction outcomes of 9253 adults aged 60+ years were extracted from the 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). Individual data were linked to census socioeconomic data with city-level characteristics and LTCI policy variable. Multilevel lagged regression models investigated the impact of LTCI policy on health and satisfaction with health services, after controlling for baseline individual- and city-level covariates. RESULTS: Of 125 cities in the dataset, 21 (16.8%) had adopted LTCI. These city inhabitants had significantly better self-rated health and higher satisfaction relative to cities without LTCI policies when environmental- and personal-level characteristics were modeled. Health benefits of LTCI were stronger after policy announcement and were particularly observed among rural older adults and those with chronic conditions. Results also suggest that LTCI's positive effects on satisfaction spill over to middle-aged adults. CONCLUSION: Expanding coverage and eligibility to LTCI for all older Chinese could improve health and well-being.

Changing Employment and Work Schedule Patterns over the 30 Working Years-A Sequential Cluster Analysis.

OBJECTIVE: As labor markets have become increasingly volatile and precarious since 1980s, more workers are susceptible to working conditions such as unpredictable and unstable hours, threatening their economic security. However, our understanding of employment patterns regarding the changes in work schedules over our working lives has yet been established. This study builds our knowledge in this area by paying attention to how social positions may shape the specific work schedule patterns over our working lives. METHODS: We used the National Longitudinal Survey of Youth-1979 (NLSY79) to examine our research questions. NLSY79 follows a nationally representative sample of United States men and women between the ages of 14 and 22 when first interviewed in 1979. The participants were then interviewed annually until 1994 and then biennially thereafter. We first conducted a sequence analysis to examine work schedule patterns between ages 22 and 53 (n = 7987). We then used a multinomial logit regression to examine the factors contributing to specific work schedule patterns, with attention to social position. RESULTS: Our sequence analysis results suggest five work schedule patterns during 31 years of adult life: working only standard hours (25%), mainly standard hours with some portions of nonstandard hours (38%), standard hours during early working years but transitioning to either largely variable or mainly evening or night hours (14% and 13%), and mostly not working (10%). Our multinomial logit analysis indicates that being non-Hispanic Black, having a high school degree or below, or having ever experienced poverty or welfare by age 23 were more likely to have a nonstandard work schedule pattern than their counterparts. CONCLUSIONS: Our analysis underscores the dynamic employment patterns over our working lives, with some groups more likely than others to be engaged in nonstandard or volatile work schedules. Importantly, the groups likely to be subject to nonstandard work schedules also tend to have relatively disadvantaged social positions, thus worsening their vulnerability in securing work characterized by stability and economic security.

Economic strain, parental education and psychotic experiences among college students in the United States: Findings from the Healthy Minds Study 2020.

AIM: Socioeconomic status (SES) is linked to psychosis, and much can be learned by examining how various indicators of SES-specifically economic strain and intergenerational transfer of resources-are related to sub-threshold psychotic experiences among college students. METHODS: Using data from the Healthy Minds Survey (September 2020-December 2020), we used multivariable logistic regression models to examine the associations between five SES indicators and 12-month psychotic experiences, adjusting for age, gender and race/ethnicity. We also examined the count of predictors and psychotic experiences. RESULTS: Each indicator of economic strain was associated with greater odds of psychotic experiences. In particular, increasing levels of financial stress (current, childhood and pandemic-related) were associated with greater odds of psychotic experiences in a dose-response fashion. Food insecurity was associated with double the odds of psychotic experiences. In terms of intergenerational transfer of resources, having either one or no parents who attended college was associated with significantly greater odds of having psychotic experiences, when compared with having both parents who attended college. Examining all predictors in the same model, only childhood and current financial stress and food insecurity were significantly associated with psychotic experiences. The count of predictors was significantly associated with greater odds of having psychotic experiences in a dose-dependent fashion. CONCLUSIONS: Among college students, economic strain and intergenerational transfer of resources were associated with recent psychotic experiences, highlighting the importance of economic interventions targeting young adults to influence risk for psychosis.

Containment, Health, and Social Policies in the Time of COVID-19 - Determinants and Outcomes of Initial Responses across 120 Countries.

The coronavirus disease 2019 (COVID-19) pandemic has triggered an unprecedented number of policy responses around the world across multiple policy domains. While governments have combined containment and health policies with social policies (CHSPs) during the initial phase of the pandemic in various ways, the current literature offers little knowledge of the patterns of these combinations and their determinants and outcomes. This paper fills this gap by investigating CHSP combinations across ≥120 countries. We further examined whether the CHSP response was determined by political regimes or compensation hypotheses-serving the purposes of responding to pre-existing economic downturns, inequality or social unrest. We also investigated the associations between CHSP responses and mobility, virus infection and unemployment. Using policy data from the Oxford COVID-19 Government Response Tracker, results from sequence analysis indicated that governments' CHSP responses could be clustered into five categories: high social policies (SPs), middle SPs, containment and health (CH) leading SPs, low SPs and gradual high SPs. We used multinomial regression models to investigate determinants of CHSP responses. We found that CHSP responses did not differ by political regimes, and CHSP combinations were not driven by compensation hypotheses. Instead, gross domestic product per capita and government effectiveness were the key drivers for high levels of policy responses. We also found that low SP responses were associated with fewer mobility changes. Taken together, our findings suggest that lower-income countries required more support and resources in order for them to adopt necessary CH and SP responses.

A Multifaceted Intervention with Savings Incentives to Reduce Multidimensional Child Poverty: Evidence from the Bridges Study (2012-2018) in Rural Uganda.

Using a randomized controlled trial design, we examine the effects of savings incentives (match rate 1:1 versus 1:2) with mentorship and financial trainings on child poverty among 1383 orphaned children (mean age 12.7 years at baseline) in rural Uganda. Given the difficulty to capture child poverty using monetary measures, we use a multidimensional class of poverty that captures four dimensions: health, assets, housing, and behavioral risks. Results show that children in treatment groups experienced reductions in poverty incidence by 10 percentage points (or deprivation score by 8 percent) relative to control group counterparts at four years post-baseline, and a higher savings incentive led to stronger effects. Further, children in treatment groups were more likely to escape the poverty trap. Finally, we assess the robustness of these results to various weighting structures. This study offers a unique evidence on effectiveness of a multifaceted intervention targeting children in alleviating poverty.

State TANF Time Limit and Work Sanction Stringencies and Long-Term Trajectories of Welfare Use, Labor Supply, and Income.

While the 1996 welfare reform increased employment and reduced the participation of the Temporary Assistance for Needy Families (TANF) program immediately after its inception, little is known about the extent to which the reform and stringencies of time limit and work sanction policy features have impacted individuals in the long term. This study used the Survey of Income and Program Participation 1996, 2001, and 2004 panels (1996-2007) and a difference-in-difference-in-difference design to follow low-skilled single mothers' trajectories of welfare use, labor supply, and income for 10 years after the welfare reform and compare how these trajectories differ by stringencies of state work sanction and time limit policies. The findings indicate that welfare reform had sustained impacts on reducing welfare use (TANF and the Supplemental Nutrition Assistance Program [SNAP] program) and increasing employment. Stringent work sanction and time limit policies were associated with lower TANF participation rates in the long term, but only short time limit policies were associated with reduced SNAP participation. Neither stringent policy feature increased employment nor income. The differential effects by race were also examined and discussed.

Psychiatric problems among returned migrants in Mexico: updated findings from the Mexican Migration Project.

PURPOSE: Migration is often a stressful process that can have deleterious effects on health. We study the potential mental health consequences of migration by comparing Mexican migrants to the United States who have since returned to Mexico with Mexicans who have never migrated. METHODS: Data from the Mexican Migration Project were used to compare returned migrants and non-migrants in Mexico for the years 2007-2016 (N = 7716). Random intercept logistic regression models were used to estimate the associations between characteristics of migration and psychiatric problems. Coarsened exact matching was implemented to account for the selection bias inherent to migration. RESULTS: Relatively healthier Mexicans were more likely to migrate to the United States, regardless of their documentation status. Returned migrants in Mexico who traveled to the United States while undocumented were significantly more likely to report that they experienced psychiatric problems when compared with non-migrant Mexicans, even after adjusting for demographic, socioeconomic, pre-migration health, and community-level factors. CONCLUSIONS: Undocumented return migrants in Mexico are at-risk of developing psychiatric problems, despite evidence that suggests migrants tend to be healthier than non-migrants before they travel to the United States. Mental health services should encompass strategies for migrants on both sides of the border.

Acculturative stress, disability, and health treatment utilization among Asian and Latin American immigrants in the United States.

PURPOSE: Empirical research has largely ignored the potential links between immigration-related stress and disability as well as immigration-related stress and health service utilization despite increasing scholarship on the association between acculturative stress and health. This study examined the associations between acculturative stress, disability, and health treatment utilization among Asian and Latin American immigrants in the United States. METHODS: Data were from the National Latino and Asian American Study (NLAAS), a nationally representative survey of Asians and Latinos living in the United States. The analytic sample contained 2653 immigrants. We utilized multivariable logistic regression and negative binomial regression analyses to examine the associations between acculturative stress and disability domains. We also examined the association between acculturative stress and treatment utilization, as this may have implications for how to best intervene to address any functional disability related to acculturative stress. RESULTS: Acculturative stress was significantly associated with self-reported disability across five domains: self-care, cognition, mobility, time out of role, and social interaction. Additionally, acculturative stress was significantly associated with a greater frequency of disability domains. Acculturative stress was not significantly associated with utilization of services from mental health or general health sectors, but was significantly and positively associated with utilization of non-health care services. The findings were robust regarding the inclusion of everyday discrimination as well as demographic and socioeconomic covariates. CONCLUSIONS: Acculturative stress may be an important yet overlooked correlate of disability among immigrants in the United States. Non-health care services may provide an effective pathway for intervening for these individuals.

State dream acts and education, health and mental health of Mexican young adults in the U.S.

We investigate the education, health and mental health effects of state policies that allowed or explicitly banned tuition subsidy and financial aid to undocumented college students using the National Health Interview Survey (NHIS) for 1998-2013. Our analysis suggests that an explicit ban on tuition subsidy or enrollment in public colleges lowered college education of non-citizen Mexican young adults by 5.4-11.6 percentage points. We find some evidence that in-state tuition and access to financial aid improved self-reported health and reduced mental health distress, and ban on in-state-tuition/enrollment increased mental health distress among non-citizen Mexican young adults: estimated effects are generally significant in first-difference models and models that include state-specific cubic trends, and often insignificant in difference-in-difference models.

Effects of Financial Incentives on Saving Outcomes and Material Well-Being: Evidence From a Randomized Controlled Trial in Uganda.

The use of savings products to promote financial inclusion has increasingly become a policy priority across sub-Saharan Africa, yet little is known about how families respond to varying levels of savings incentives and whether the promotion of incentivized savings in low-resource settings may encourage households to restrict expenditures on basic needs. Using data from a randomized controlled trial in Uganda, we examine: 1) whether low-income households enrolled in an economic-empowerment intervention consisting of matched savings, workshops, and mentorship reduced spending on basic needs and 2) how varied levels of matching contributions affected household savings and consumption behavior. We compared primary school-attending AIDS-affected children (N = 1,383) randomized to a control condition with two intervention arms with differing savings-match incentives: 1:1 (Bridges) and 1:2 (Bridges PLUS). We found that: 1) 24 months post-intervention initiation, children in Bridges and Bridges PLUS were more likely to have accumulated savings than children in the control condition; 2) higher match incentives (Bridges PLUS) led to higher deposit frequency but not higher savings in the bank; 3) intervention participation did not result in material hardship; and 4) in both intervention arms, participating families were more likely to start a family business and diversify their assets.

Cost-Effectiveness of a Savings-Led Economic Empowerment Intervention for AIDS-Affected Adolescents in Uganda: Implications for Scale-up in Low-Resource Communities.

PURPOSE: Nearly 12 million children and adolescents in sub-Saharan Africa have lost one or both parents to AIDS. Within sub-Saharan Africa, Uganda has been greatly impacted, with an estimated 1.2 million orphaned children, nearly half of which have experienced parental loss due to the epidemic. Cost-effective and scalable interventions are needed to improve developmental outcomes for these children, most of whom are growing up in poverty. This article examines the direct impacts and cost-effectiveness of a savings-led family economic empowerment intervention, Bridges to the Future, that employed varying matched savings incentives to encourage investment in Ugandan children orphaned by AIDS. METHODS: Using data from 48 primary schools in southwestern Uganda, we calculate per-person costs in each of the two treatment arms-Bridges (1:1 match savings) versus Bridges PLUS (1:2 match savings); estimate program effectiveness across outcomes of interest; and provide the ratios of per-person costs to their corresponding effectiveness. RESULTS: At the 24-month postintervention initiation, children in the two treatment arms showed better results in health, mental health, and education when compared to the usual care condition; however, no statistically significant differences were found between treatment arms with the exception of school attendance rates which were higher for those in Bridges PLUS. Owing to the minimal cost difference between the Bridges and Bridges PLUS arms, we did not find substantial cost-effectiveness differences across the two treatment arms. CONCLUSION: After 24 months, an economic intervention that incorporated matched savings yielded positive results on critical development outcomes for adolescents orphaned by AIDS in Uganda. The 1:1 and 1:2 match rates did not demonstrate variable levels of cost-effectiveness at 24-month follow-up, suggesting that governments intending to incorporate savings-led interventions within their social protection frameworks may not need to select a higher match rate to see positive developmental outcomes in the short term. Further research is required to understand intervention impacts and cost-effectiveness after a longer follow-up period.

Unhealthy assimilation or persistent health advantage? A longitudinal analysis of immigrant health in the United States.

Existing evidence on immigrant health assimilation, which is largely based on cross-sectional data, suggests that immigrants' initial health advantage erodes over time. This study uses longitudinal data to directly compare the self-rated health trajectories of immigrants and the native-born population. Data come from four panels of the Survey of Income and Program Participation (1996, 2001, 2004, and 2008), with each panel containing 2-4 years of health information. Results show that immigrants' self-rated health remained stable during the period under study, but there was a concomitant decline in health for the native-born population. This result pointed to a persistent health advantage of immigrants during the period under study. The pattern held for immigrants of different length of residence and was especially salient for those originally from Latin America and Asia. Our findings that immigrants maintain their health advantage do not support the pattern of unhealthy assimilation commonly reported in cross-sectional studies.

Health of newly arrived immigrants in Canada and the United States: Differential selection on health.

Canada and the U.S. are two major immigrant-receiving countries characterized by different immigration policies and health care systems. The present study examines whether immigrant health selection, or the "healthy immigrant effect", differs by destination and what factors may account for differences in immigrant health selection. We use 12 years of U.S. National Health Interview Survey and Canadian Community Health Survey data to compare the risks of overweight/obesity and chronic health conditions among new immigrants in the two countries. Results suggest a more positive health selection of immigrants to Canada than the U.S. Specifically, newly arrived U.S. immigrants are more likely to be overweight or obese and have serious chronic health conditions than their Canadian counterparts. The difference in overweight/obesity was explained by differences in source regions and educational levels of immigrants across the two countries. But this is not the case for serious chronic conditions. These results suggest that immigration-related policies can potentially shape immigrant health selection.

Women's Short-Term Employment Trajectories Following Birth: Patterns, Determinants, and Variations by Race/Ethnicity and Nativity.

Despite a large literature documenting the impact of childbearing on women's wages, less understanding exists of the actual employment trajectories that mothers take and the circumstances surrounding different paths. We use sequence analysis to chart the entire employment trajectory for a diverse sample of U.S. women by race/ethnicity and nativity in the first year following childbirth. Using data from the 1996-2008 panels of the Survey of Income and Program Participation and sample selection models, we find that women employed before childbirth show a high degree of labor market continuity. However, a notable share of them (24 %) took less stable paths by dropping out or scaling back work. In addition, mothers' attachment to the labor force is simultaneously supported by personal endowments and family resources yet constrained by economic hardship and job characteristics. Moreover, mothers' employment patterns differ by race/ethnicity and nativity. Nonwhite women (blacks, Hispanics, and Asians) who were employed before childbirth exhibited greater labor market continuation than white women. For immigrant women, those with a shorter length of residence were more likely to curtail employment than native-born women, but those with longer duration of residence show greater labor force attachment. We discuss the implications of these findings for income inequality and public policy.

Immigrant employment and earnings growth in Canada and the USA: evidence from longitudinal data.

We study the short-term trajectories of employment, hours worked, and real wages of immigrants in Canada and the U.S. using nationally representative longitudinal datasets covering 1996-2008. Models with person fixed effects show that on average immigrant men in Canada do not experience any relative growth in these three outcomes compared to men born in Canada. Immigrant men in the U.S., on the other hand, experience positive annual growth in all three domains relative to U.S. born men. This difference is largely on account of low-educated immigrant men, who experience faster or longer periods of relative growth in employment and wages in the U.S. than in Canada. We further compare longitudinal and cross-sectional trajectories and find that the latter over-estimate wage growth of earlier arrivals, presumably reflecting selective return migration.

Applying a Family-Level Economic Strengthening Intervention to Improve Education and Health-Related Outcomes of School-Going AIDS-Orphaned Children: Lessons from a Randomized Experiment in Southern Uganda.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Women's land ownership and risk of HIV infection in Kenya.

Theory predicts that land ownership empowers women to avoid HIV acquisition by reducing their reliance on risky survival sex and enhancing their ability to negotiate safer sex. However, this prediction has not been tested empirically. Using a sample of 5511 women working in the agricultural sector from the 1998, 2003 and 2008-09 Kenya Demographic and Health Surveys, we examined the relationship between women's land ownership and participation in transactional sex, multiple sexual partnerships and unprotected sex, and HIV infection status. We controlled for demographic characteristics and household wealth, using negative binomial and logistic regression models. Women's land ownership was associated with fewer sexual partners in the past year (incidence rate ratio, 0.98; 95% confidence interval [CI], 0.95-1.00) and lower likelihood of engaging in transactional sex (odds ratio [OR], 0.67; 95% CI: 0.46-0.99), indicators of reduced survival sex, but was not associated with unprotected sex with casual partners (OR, 0.64; 95% CI, 0.35-1.18) or with unprotected sex with any partner among women with high self-perceived HIV risk (OR, 1.02; 95% CI, 0.57-1.84), indicating no difference in safer sex negotiation. Land ownership was also associated with reduced HIV infection among women most likely to engage in survival sex, i.e., women not under the household headship of a husband (OR, 0.40; 95% CI, 0.18-0.89), but not among women living in husband-headed households, for whom increased negotiation for safer sex would be more relevant (OR, 1.74; 95% CI, 0.92-3.29). These findings suggest that reinforcing women's land rights may reduce reliance on survival sex and serve as a viable structural approach to HIV prevention, particularly for women not in a husband's household, including unmarried women and female household heads.

Family economic strengthening and mental health functioning of caregivers for AIDS-affected children in rural Uganda.

In sub-Saharan Africa, many extended families assume the role of caregivers for children orphaned by AIDS (AIDS-affected children). The economic and psychological stress ensued from caregiving duties often predispose caregivers to poor mental health outcomes. Yet, very few studies exist on effective interventions to support these caregivers. Using data from a randomized controlled trial called Suubi-Maka (N = 346), this paper examines whether a family economic strengthening intervention among families caring for AIDS-affected children (ages 12-14) in Uganda would improve the primary caregivers' mental health functioning. The Suubi-Maka study comprised of a control condition (n = 167) receiving usual care for AIDS-affected children, and a treatment condition (n = 179) receiving a family economic strengthening intervention, including matched savings accounts, and financial planning and management training to incentivize families to save money for education and/or family-level income generating projects. This paper uses data from baseline/pre-intervention (wave 1) interviews with caregivers and 12-month post-intervention initiation (wave 2). The caregiver's mental health measure adapted from previous studies in sub- Saharan Africa had an internal consistency of .88 at wave 1 and .90 at wave 2. At baseline, the two study groups did not significantly differ on caregiver's mental health functioning. However, at 12-month follow-up, multiple regression analysis located significant differences between the two study groups on mental health functioning. Specifically, following the intervention, caregivers in the treatment condition reported positive improvements on their mental health functioning, especially in the symptom areas of obsession-compulsion, interpersonal sensitivity, hostility, and psychoticism. Findings point to a need for programs and policies aimed at supporting caregivers of AIDS-affected children to begin to consider incorporating family-level economic strengthening components in their usual care protocols, especially in low-resource countries of sub-Saharan Africa. Economic empowerment programming may help enhance the well-being of caregivers and their families.