Relation of poverty with treatment-seeking behavior and antibiotic misuse among UTI patients in Pakistan.

Objective: The current study aimed to assess the relation between multi-dimension poverty, treatment-seeking behavior, and antibiotic misuse among urinary tract infection (UTI) patients. Method: A cross-sectional approach was utilized to recruit patients who had a history of UTI in the previous month from two provinces of Pakistan. The treatment-seeking behavior and antibiotic misuse data were collected on a self-developed questionnaire, whereas the poverty data were collected on a modified multi-dimension poverty index (MPI). Descriptive statistics were applied to summarize the data. The logistic regression analysis was carried out to assess the association of multi-dimension poverty with patient treatment-seeking behavior and antibiotic misuse. Results: A total of 461 participants who had UTI symptoms in the previous month were recruited. Most of the participants in the severely deprived stage treated the UTI (p < 0.001); however, there was a high proportion of the participants who consulted with friends and family for UTI treatment (p < 0.001). The patients with deprivation status (deprived and severely deprived) were less associated with formal consultation. The poorer subgroups were less likely to practice antibiotic course completion. Conclusion: The current study highlighted that poverty plays an important role in antibiotic misuse. Poorer subgroups were associated with informal consultations and the incompletion of the antibiotic course. Further studies are needed to explore the potential role of poverty in treatment-seeking behavior and antibiotic misuse.

Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988-2018.

BACKGROUND: Mean cardiovascular health has improved over the past several decades in the United States, but it is unclear whether the benefit is shared equitably. This study examined 30-year trends in cardiovascular health using a suite of income equity metrics to provide a comprehensive picture of cardiovascular income equity. METHODS: The study evaluated data from the 1988-2018 National Health and Nutrition Examination Survey. Survey groupings were stratified by poverty-to-income ratio (PIR) category, and the mean predicted 10-year risk of a major cardiovascular event or death based on the pooled cohort equations (PCE) was calculated (10-year PCE risk). Equity metrics including the relative and absolute concentration indices and the achievement index-metrics that assess both the prevalence and the distribution of a health measure across different socioeconomic categories-were calculated. RESULTS: A total of 26 633 participants aged 40 to 75 years were included (mean age, 53.0-55.5 years; women, 51.9%-53.0%). From 1988-1994 to 2015-2018, the mean 10-year PCE risk improved from 7.8% to 6.4% (P<0.05). The improvement was limited to the 2 highest income categories (10-year PCE risk for PIR 5: 7.7%-5.1%, P<0.05; PIR 3-4.99: 7.6%-6.1%, P<0.05). The 10-year PCE risk for the lowest income category (PIR <1) did not significantly change (8.1%-8.7%). In 1988-1994, the 10-year PCE risk for PIR <1 was 6% higher than PIR 5; by 2015-2018, this relative inequity increased to 70% (P<0.05). When using metrics that account for all income categories, the achievement index improved (8.0%-7.1%, P<0.05); however, the achievement index was consistently higher than the mean 10-year PCE risk, indicating the poor persistently had a greater share of adverse health. CONCLUSIONS: In this serial cross-sectional survey of US adults spanning 30 years, the population's mean 10-year PCE risk improved, but the improvement was not felt equally across the income spectrum.

Assessing New York City's COVID-19 Vaccine Rollout Strategy: A Case for Risk-Informed Distribution.

This study reviews the impact of eligibility policies in the early rollout of the COVID-19 vaccine on coverage and probable outcomes, with a focus on New York City. We conducted a retrospective ecological study assessing age 65+, area-level income, vaccination coverage, and COVID-19 mortality rates, using linked Census Bureau data and New York City Health administrative data aggregated at the level of modified zip code tabulation areas (MODZCTA). The population for this study was all individuals in 177 MODZCTA in New York City. Population data were obtained from Census Bureau and New York City Health administrative data. The total mortality rate was examined through an ordinary least squares (OLS) regression model, using area-level wealth, the proportion of the population aged 65 and above, and the vaccination rate among this age group as predictors. Low-income areas with high proportions of older people demonstrated lower coverage rates (mean vaccination rate 52.8%; maximum coverage 67.9%) than wealthier areas (mean vaccination rate 74.6%; maximum coverage 99% in the wealthiest quintile) in the first 3 months of vaccine rollout and higher mortality over the year. Despite vaccine shortages, many younger people accessed vaccines ahead of schedule, particularly in high-income areas (mean coverage rate 60% among those 45-64 years in the wealthiest quintile). A vaccine program that prioritized those at greatest risk of COVID-19-associated morbidity and mortality would have prevented more deaths than the strategy that was implemented. When rolling out a new vaccine, policymakers must account for local contexts and conditions of high-risk population groups. If New York had focused limited vaccine supply on low-income areas with high proportions of residents 65 or older, overall mortality might have been lower.

Association of socioeconomic status and overactive bladder in US adults: a cross-sectional analysis of nationally representative data.

Background: Socioeconomic status inequality is an important variable in the emergence of urological diseases in humans. This study set out to investigate the association between the prevalence of overactive bladder (OAB) and the poverty income ratio (PIR) that served as a more influential indicator of socioeconomic status compared to education and occupation. Method: Data from the National Health and Nutrition Examination Survey (NHANES) conducted from 2007 to 2020 were used in this cross-sectional study. The association between the PIR and OAB was examined using weighted multivariate logistic regression and weighted restricted cubic splines (RCS). Additionally, interaction analysis was used for investigation to the connections between PIR and OAB in various covariate groups in order to confirm the stability of the results. Results: We observed a noteworthy inverse association between PIR and OAB after adjusting for potential confounding variables (OR = 0.87, 95% CI, 0.84-0.90, p < 0.0001). PIR was transformed into categorical variables, and the association held steady after that (1.0 < PIR <4.0 vs. PIR ≤ 1.0, OR = 0.70, 95% CI =0.63-0.77, p < 0.0001; PIR ≥ 4.0 vs. PIR ≤ 1.0, OR = 0.56, 95% CI =0.48-0.65, p < 0.0001). Additionally, RCS analysis showed that PIR and OAB had a negative nonlinear response relationship. Subgroup analyses showed that the inverse association between PIR and prevalence of OAB was stronger in obese than in nonobese individuals (P for interaction < 0.05). Conclusion: In our study, we observed a significant negative association between the PIR and the prevalence of OAB. In the future, PIR could be used as a reference standard to develop strategies to prevent and treat OAB.

Higher consumption of ultra-processed foods is associated with obesity and abdominal obesity in socially vulnerable Brazilian women.

This study aimed to assess the consumption of ultra-processed foods (UPF) and identify their association with obesity and abdominal obesity in adult women of reproductive age living in situations of social vulnerability in Maceió, Northeastern Brazil. This was a cross-sectional study carried out between October 2020 and May 2021. An anthropometric evaluation was carried out to assess obesity and abdominal obesity. A dietary assessment was also conducted using a 24-h food recall to determine the calorie intake from UPF. To estimate intra-individual variability in food consumption, the probabilistic Multiple Source Method was used. These data in the form of tertiles were used to analyse the association between the consumption of UPF and obesity and abdominal obesity. Logistic regressions were used to analyse the association. A directed acyclic graph (DAG) was created for this analysis. This study included 1702 women of which 53.7% were 31 years old or older, and 74.2% lived in poverty. It identified that 36.5% and 38.1% of the women had obesity and abdominal obesity, respectively, and that an average of 33.8% of calories consumed came from UPF. In the analysis of association guided by the DAG, it was observed that women with a high-calorie intake from UPF had a 1.3 times higher probability of being obese. It was also observed that women with a moderate and high-calorie intake from UPF were 1.4 and 1.3 times more likely, respectively, to have abdominal obesity. Thus, it can be concluded that socially vulnerable women in Brazil have a relatively high consumption of UPF and that this condition increases the probability of obesity in this population group.

Associations between perceived discrimination experiences, treatment adherence self-efficacy, and depressive symptoms among people living with HIV in the Southern United States.

This study examined associations between perceived discrimination, treatment adherence self-efficacy, and depressive symptoms among people living with HIV (PLHIV) in the Southern United States. Cross-sectional survey data were collected from 402 PLHIV who self-reported on interpersonal discrimination experiences based on HIV status, sexuality, gender, income, and living condition. Participants also reported on adherence self-efficacy and depressive symptoms. We employed K-means clustering to identify groups based on discrimination experiences, and logistic regressions to examine group differences on adherence self-efficacy and depressive symptoms. Results suggested three groups: a cluster with high perceived discrimination across all identities/conditions (n = 41; 11%; Cluster 1); a cluster with high perceived discrimination based on HIV status, income, and living condition (n = 49; 13%; Cluster 2); and a cluster with low perceived discrimination across all identities/conditions (n = 288; 76%; Cluster 3). Compared to Cluster 3, Cluster 1 and 2 had 2.22 times (p = .037) and 3.98 times (p<.001) greater odds of reporting depressive symptoms. Compared to Cluster 3, Cluster 2 had 3.40 times (p = .003) greater odds of reporting lower adherence self-efficacy. Findings demonstrate the need for individual-level support for PLHIV with discrimination histories, and broader efforts to end the stigma, discrimination, and marginalization of PLHIV based on HIV status and other characteristics.

The impact of an economic empowerment intervention on intimate partner violence among women engaged in sex work in southern Uganda: A cluster randomized control trial.

Women engaged in sex work (WESW) are at heightened risk of experiencing intimate partner violence (IPV) compared to women in the general population. This study examines the impact of an economic empowerment intervention on IPV among WESW in Southern Uganda. We used data from 542 WESW in Southern Uganda recruited from 19 HIV hotspots between June 2019 and March 2020. Eligible participants were 18+ years old, engaged in sex work-defined as vaginal or anal sexual intercourse in exchange for money, alcohol, or other goods, reported at least one episode of unprotected sexual intercourse in the past 30 days with a paying, casual, or regular sexual partner (spouse, main partner). We analyzed data collected at baseline, 6, and 12months of follow up. To examine the impact of the intervention on IPV, separate mixed-effects logistic regression models were run for each type of IPV (physical, emotional, and sexual) as experienced by participants in the last 90 days. Results show that the intervention was efficacious in reducing emotional and physical IPV as evidenced by a statistically significant intervention main effect for emotional IPV, χ2(1) = 5.96, p = 0.015, and a significant intervention-by-time interaction effect for physical IPV, χ2(2) = 13.19, p < 0.001. To qualify the intervention impact on physical IPV, pairwise comparisons showed that participants who received the intervention had significantly lower levels of physical IPV compared to those in the control group at six months (contrasts = -0.12 (95% CI: -0.22, -0.02), p = 0.011). The intervention, time, and intervention-by-time main effects for sexual IPV were not statistically significant. Our findings suggest economic empowerment interventions as viable strategies for reducing emotional IPV among WESW. However, it is also essential to understand the role of interventions in addressing other forms of IPV especially for key populations at high risk of violence, HIV, and STI. The study was registered at ClinicalTrials.gov, ID: NCT03583541.

Pursuit of Equity: Women on a Low Income Navigating Access to Health and Social Services in Canada.

BACKGROUND: Existing research highlights the role of social determinants of health, such as education and housing, in predicting health outcomes and the challenges that arise from deficiencies in these areas, often linked to societal inequities. Gender and income are recognized as social determinants of health, yet the complexities of their interplay, particularly for women with low income seeking health and social services in Canada, need more exploration. OBJECTIVE: This study investigates how gender and income intersect to affect access to health and social services for Canadian women with low income. METHODS: Employing a participatory action approach with arts-based and interpretive methodologies, the study partnered with a non-profit organization to engage five women through photovoice, interviews, and a focus group, aiming to capture their experiences in accessing services. RESULTS: The analysis revealed three primary themes: the labyrinth-like complexity of navigating health and social service systems, the importance of mental health sanctuaries, and the value of supportive networks. Participants reported difficulties and frustrations in system navigation, often feeling ignored by service providers. Contrarily, community agencies provided essential non-judgmental support, including daily necessities and emotional care, with the companionship of pets also being a notable source of comfort. CONCLUSION: The findings advocate for a shift towards more person-centred care in health and social service systems to better serve women in vulnerable positions, emphasizing the need to simplify the process of accessing services and ensuring that service providers recognize and address the unique challenges faced by equity-deserving groups.

Do hospitalizations push households into poverty in India: evidence from national data.

Introduction: High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it. Methods: The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment. Results: Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities. Conclusion: In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Breaking the poverty trap in an ecologically fragile region through ecological engineering: A close-up look at long-term changes in ecosystem services.

Ecological vulnerability and poverty are interrelated and must be addressed together. The resolution of this issue will help us to meet the challenges during the process of implementing concrete actions for realizing the 2030 UN sustainable development goals (SDGs). Ecological restoration projects (ERPs) can enhance ecosystem services (ESs) while providing policy support for improving people's livelihoods. However, processes and mechanisms of ERPs on the ecological environment and socioeconomic development in poverty-stricken and ecologically fragile areas have rarely been studied. To address these issues, we conducted a comparative analysis on the changes of land use and land cover (LULC), ecosystem services (ESs), and socioeconomic development in Bijie City, a karst rocky desertification area in southwest China, before and after the implementation of ERPs in 2000, as well as the complex relationship between these factors. ERPs have affected LULCs, ESs, socioeconomics, and poverty reduction significantly since 2000. Specifically, the total ecosystem service value (ESV) in the study area has increased by more than 3 times in the past 30 years, with the ESV of tourism services and carbon storage increasing the most, from CNY 0.001 and 337.07 billion in 1990 to CNY 11.07 and 108.97 billion in 2019, respectively. The correlation between ESs is mainly synergistic, while the tradeoff between carbon storage and water yield is in a fluctuating upward trend. LULC conversion of cropland to green, and cropland to water, wetland and shrubs has positive effects on carbon storage and water yield, respectively. During study period, GDP, urbanization increased by over 70 times, 5 times, respectively, whereas poverty population, poverty incidence, and employment rate of various sectors (i.e., agriculture, forest, animal, and fishery, or AFAF) decreased by 96.4%, 97.7%, and 18.24%, respectively. Our findings emphasized that ERPs can effectively help poor and ecologically fragile areas to get out of the poverty trap and achieve the "win-win" goals of ecological and socio-economic sustainable development. These results have profound environmental management references to China and other developing countries around the world in realizing ecological restoration, poverty reduction, and the SDGs.

Rainfall's impact on agricultural production and government poverty reduction efficiency in China.

The quest to eradicate poverty, central to the United Nations Sustainable Development Goals (SDGs), poses a significant global challenge. Advancement in sustainable rural development is critical to this effort, requiring the seamless integration of environmental, economic, and governmental elements. Previous research often omits the complex interactions among these factors. Addressing this gap, this study evaluates sustainable rural development in China by examining the interconnection between agricultural production and government-led poverty reduction, with annual rainfall considered an influential factor of climate change impacts on these sectors and overall sustainability. Utilizing a Meta-frontier entropy network dynamic Directional Distance Function (DDF) within an exogenous Data Envelopment Analysis (DEA) model, we categorize China's 27 provinces into southern and northern regions according to the Qinling-Huaihe line for a comparative study of environmental, economic, and governmental efficiency. This innovative approach overcomes the limitations of previous static analyses. The findings reveal: (1) Rainfall, as an exogenous variable, significantly affects agricultural production efficiency. (2) The overall efficiency in both southern and northern regions increases when accounting for rainfall. (3) Government effectiveness in poverty reduction is comparatively lower in the northern region than in the southern region when rainfall is considered. These insights underscore the importance of including climatic variables in sustainable development policies and emphasize the need for region-specific strategies to bolster resilience against climatic challenges.

The impact of poverty and socioeconomic status on brain, behaviour, and development: a unified framework.

In this article, we, for the first time, provide a comprehensive overview and unified framework of the impact of poverty and low socioeconomic status (SES) on the brain and behaviour. While there are many studies on the impact of low SES on the brain (including cortex, hippocampus, amygdala, and even neurotransmitters) and behaviours (including educational attainment, language development, development of psychopathological disorders), prior studies did not integrate behavioural, educational, and neural findings in one framework. Here, we argue that the impact of poverty and low SES on the brain and behaviour are interrelated. Specifically, based on prior studies, due to a lack of resources, poverty and low SES are associated with poor nutrition, high levels of stress in caregivers and their children, and exposure to socio-environmental hazards. These psychological and physical injuries impact the normal development of several brain areas and neurotransmitters. Impaired functioning of the amygdala can lead to the development of psychopathological disorders, while impaired hippocampus and cortex functions are associated with a delay in learning and language development as well as poor academic performance. This in turn perpetuates poverty in children, leading to a vicious cycle of poverty and psychological/physical impairments. In addition to providing economic aid to economically disadvantaged families, interventions should aim to tackle neural abnormalities caused by poverty and low SES in early childhood. Importantly, acknowledging brain abnormalities due to poverty in early childhood can help increase economic equity. In the current study, we provide a comprehensive list of future studies to help understand the impact of poverty on the brain.

Coping and Empowerment Preventive Intervention Buffers Early Adolescent Neuroendocrine-Related Risk for Internalizing Problems.

There is an absence of mechanism-driven interventions equipped to reduce the large mental health disparities that exist for preadolescent youth living in poverty. Building a Strong Identity and Coping Skills (BaSICS) is a preventive intervention designed to target multiple aspects of poverty-related stress adaptation, including altered neuroendocrine function. The purpose of the current study was to examine whether pre-post shifts in preadolescent hypothalamic-pituitary-adrenal (HPA) activation could longitudinally predict internalizing outcomes and to determine whether BaSICS could buffer such HPA-related risk for psychopathology. Low-income youth (n=112) ages 11-12 years were randomized to the 16-session intervention or assessment-only control (53% intervention; 54% female; 40% Hispanic, 63% Black, 20% White). Youth completed questionnaires and the Trier Social Stress Test, and provided cortisol via saliva at six timepoints during the 90-minute assessment. Adjusting for pre-intervention Cortisol Area Under the Curve-Ground (CAUCg) scores and internalizing problems, post-intervention CAUCg and intervention main and interactive effects were modeled as predictors of internalizing outcomes across post-intervention, 6-month, and 12-month follow-up assessments using multilevel regression methods. A significant post-intervention CAUCg by intervention interaction emerged (B=1.198, SE=0.433, p=.006). For control youth, baseline-adjusted decreases in cortisol output were associated with increases in internalizing problems that remained stably elevated across follow-up assessments. For BaSICS youth, however, internalizing problems decreased and remained stably low following program delivery, irrespective of post-intervention increases or decreases in cortisol output.  Findings illustrate how BaSICS may buffer against HPA-related risk for internalizing psychopathology and provide support for interventions targeting biological mechanisms of risk for low-income preadolescents.

Predictors of fuel poverty and the equity of local fuel poverty support: secondary analysis of data from Bradford, England.

AIMS: Addressing fuel poverty is a critical public health issue given its recent rise in prevalence across Europe. Although previous research identifies national risk markers of fuel poverty, evidence is lacking on whether these are consistent across local geographies, and the equity of local interventions. In the UK's current economic climate, it is more crucial than ever that services benefit households in greatest need. This study aimed to determine significant predictors of fuel poverty among households in Bradford, England, comparing them to national-level predictors, and evaluate if households possessing significant fuel poverty predictors were equitably referred to a local fuel poverty service (Warm Homes Healthy People, WHHP). METHODS: A multivariate logistic regression model determined significant fuel poverty predictors in Bradford using household-level data from the Energy Saving Trust and the Low Income High Costs fuel poverty definition. Statistical testing highlighted significant differences in predictors of fuel poverty between households referred to WHHP and all Bradford households. RESULTS: Significant (p < .05) predictors of fuel poverty included: living in an area with lower average household incomes and higher proportion of ethnic minority individuals, and living in a property with a lower energy efficiency rating. Households living in a detached or older property, and homeowners were more likely to be fuel poor. Differences in the direction of the relationship with fuel poverty were identified between some national and local predictors. Most predictors were significantly (p < .05) overrepresented among WHHP households, suggesting equitable service reach. Ethnic minorities, younger people, and multiperson households were underrepresented. CONCLUSIONS: Local fuel poverty predictors were similar to many national-level predictors, but identified differences in the direction of the relationship between some national and local predictors reaffirm the value of locally focused research. WHHP successfully targeted households possessing key predictors, but should ensure that ethnic minorities, younger people, and multiperson households are equitably referred.

Exposure to Community Violence as a Mechanism Linking Neighborhood Socioeconomic Disadvantage and Neural Responses to Reward.

A growing literature links socioeconomic disadvantage and adversity to brain function, including disruptions in reward processing. Less research has examined exposure to community violence as a specific adversity related to differences in reward-related brain activation, despite the prevalence of community violence exposure for those living in disadvantaged contexts. The current study tested whether exposure to community violence was associated with reward-related ventral striatum activation after accounting for familial factors associated with differences in reward-related activation (e.g., parenting, family income). Moreover, we tested whether exposure to community violence is a mechanism linking socioeconomic disadvantage to reward-related activation in the ventral striatum. We utilized data from 444 adolescent twins sampled from birth records and residing in neighborhoods with above-average levels of poverty. Exposure to community violence was associated with greater reward-related ventral striatum activation, and the association remained after accounting for family-level markers of disadvantage. We identified an indirect pathway in which socioeconomic disadvantage predicted greater reward-related activation via greater exposure to community violence, over and above family-level adversity. These findings highlight the unique impact of community violence exposure on reward processing and provide a mechanism through which socioeconomic disadvantage may shape brain function.

Energy poverty in the Energy Community region: Interrogating policy formulation and coverage.

The capacity of the state to develop and implement policy at the complex nexus of energy infrastructure, social inequality and housing is indicative of the political priorities of governing structures and, by extension, the nature of statecraft more generally. We compare and contrast the energy poverty amelioration policies of two former Yugoslav and two post-Soviet states located outside the European Union, but seeking to join its regulatory sphere - Serbia, Montenegro, Ukraine and Georgia - against the background of deep and persistent patterns of domestic energy hardship. We are particularly interested in uncovering the time horizons, socio-technical systems and target constituencies of different policy measures, as well as energy sector-specific responses to the COVID-19 pandemic. We find that most states in the region have done little to address some of the more substantive challenges around improving housing quality, energy efficiency and gender inequality. However, energy poverty is present in the policy lexicon of all case study countries, and Ukraine, in particular, has advanced a number of more sophisticated approaches and programmes.

Living in High-Poverty Areas is Associated with Reduced Survival in Patients with Thoracoabdominal Aortic Aneurysm.

OBJECTIVES: Studies have demonstrated socioeconomic status, insurance, race, and distance impact clinical outcomes in patients with abdominal aortic aneurysms (AAA). The purpose of this study was to assess if these factors also impact clinical outcomes in patients with thoracoabdominal aortic aneurysms (TAAA). METHODS: We conducted a retrospective review of patients with TAAAs confirmed by CT imaging between 2009 to 2019 at a single institution. Patients' zip codes were mapped to American Community Survey Data to obtain geographic poverty rates. We used the standard US Census definition of high-poverty concentration, as >20% of the population living at 100% of the poverty rate. Our primary outcome was overall survival, stratified by whether the patient underwent repair. RESULTS: Of 578 patients, 575 had zip code data and were analyzed. In both the non-operative (N=268) and operative (N=307) groups there were no significant differences in age, race, co-morbidities, clinical urgency, surgery utilization, or surgery modality between patients living in high-poverty areas (N=95, 16.4%) versus not. In the non-operative group, patients from high-poverty areas were more likely to have aneurysm due to dissection (37.5 vs. 17.6%, P=0.03). In multivariate analyses, patients from high-poverty zip codes had significantly worse non-operative survival (HR 1.9, 95% 1.1-3.3, P=0.03). In the repair group, high-poverty was also a significant predictor of reduced post-operative survival (HR 1.65, 95% 1-2.63, P=0.04). Adding the Gagne Index, these differences persisted in both groups (non-operative: HR 1.93, 95% 1.01-3.70, P = 0.05; operative: HR 1.62, 95% 1.03-2.56, p = 0.04). In Kaplan-Meier analysis the difference in post-operative survival began approximately 1.5 years after repair. Private insurance was predictive of improved post-operative survival (HR 0.42, 95% 0.18- 0.95, P=0.04) but reduced non-operative survival (HR 2.05, 95% 1.01-4.14, P=0.04). Data were insufficient to determine if race impacted survival discretely from poverty status. These results were found after adjusting for age, race, sex, maximum aortic diameter, coronary artery disease, distance from the hospital, insurance, and active smoking. Interestingly, in multivariate regression, traveling greater than 100 miles was correlated with increased surgery utilization (OR 1.58, 95% 1.08-2.33, P=0.02) and long-term survival (HR 0.61, 95% 0.41-0.92, P=0.02). CONCLUSIONS: Patients with TAAA living in high-poverty areas had significantly more dissections and suffered a nearly doubled risk of mortality compared to patients living outside such areas. These data suggest that these disparities are attributed to the overall impacts of poverty and highlight the pressing need for research into TAAA disparities.

Patient Satisfaction With the Health Care Services of a Government-Financed Health Protection Scheme in Bangladesh: Cross-Sectional Study.

BACKGROUND: Since 2016, the government of Bangladesh has been piloting a health protection scheme known as Shasthyo Surokhsha Karmasuchi (SSK), which specifically targets households living below the poverty line. This noncontributory scheme provides enrolled households access to inpatient health care services for 78 disease groups. Understanding patients' experiences with health care utilization from the pilot SSK scheme is important for enhancing the quality of health care service delivery during the national-level scale-up of the scheme. OBJECTIVE: We aimed to evaluate patient satisfaction with the health care services provided under the pilot health protection scheme in Bangladesh. METHODS: A cross-sectional survey was conducted with the users of the SSK scheme from August to November 2019. Patients who had spent a minimum of 2 nights at health care facilities were selected for face-to-face exit interviews. During these interviews, we collected information on patients' socioeconomic characteristics, care-seeking experiences, and level of satisfaction with various aspects of health care service delivery. To measure satisfaction, we employed a 5-point Likert scale (very satisfied, 5; satisfied, 4; neither satisfied nor dissatisfied, 3; dissatisfied, 2; very dissatisfied, 1). Descriptive statistics, statistical inferential tests (t-test and 1-way ANOVA), and linear regression analyses were performed. RESULTS: We found that 55.1% (241/438) of users were either very satisfied or satisfied with the health care services of the SSK scheme. The most satisfactory indicators were related to privacy maintained during diagnostic tests (mean 3.91, SD 0.64), physicians' behaviors (mean 3.86, SD 0.77), services provided at the registration booth (mean 3.86, SD 0.62), confidentiality maintained regarding diseases (mean 3.78, SD 0.72), and nurses' behaviors (mean 3.60, SD 0.83). Poor satisfaction was identified in the interaction of patients with providers about illness-related information (mean 2.14, SD 1.40), availability of drinking water (mean 1.46, SD 0.76), cleanliness of toilets (mean 2.85, SD 1.04), and cleanliness of the waiting room (mean 2.92, SD 1.09). Patient satisfaction significantly decreased by 0.20 points for registration times of 16-30 minutes and by 0.32 points for registration times of >30 minutes compared with registration times of ≤15 minutes. Similarly, patient satisfaction significantly decreased with an increase in the waiting time to obtain services. However, the satisfaction of users significantly increased if they received a complete course of medicines and all prescribed diagnostic services. CONCLUSIONS: More than half of the users were satisfied with the services provided under the SSK scheme. However, there is scope for improving user satisfaction. To improve the satisfaction level, the SSK scheme implementation authorities should pay attention to reducing the registration time and waiting time to obtain services and improving the availability of drugs and prescribed diagnostic services. The authorities should also ensure the supply of drinking water and enhance the cleanliness of the facility.

1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults.

BACKGROUND: Mental health problems and financial difficulties each increase the risk of social exclusion. However, few large studies representing a broad age range have investigated the combined social effect of having both difficulties. The purpose of this cross-sectional study was to examine associations of mental health problems, financial difficulties, and the combination of both with social exclusion. METHODS: This analysis was based on responses from 28,047 adults (age > 18 years) from the general population participating in The Norwegian Counties Public Health Survey 2019. Respondents answered questions about their financial situation, mental health problems, and social exclusion. Social exclusion was measured as a lack of social support, low participation in organized social activities, low participation in other activities, missing someone to be with, feeling excluded, and feeling isolated. Adjustments for sex and age were made in multivariable logistic regression analyses. RESULTS: Having mental health problems or financial difficulties was associated with various measures of social exclusion (odds ratios [ORs] with 95% confidence intervals [CIs]: 1.33 [1.23-1.43] to 12.63 [10.90-14.64]). However, the odds of social exclusion strongly increased for respondents who reported a combination of mental health problems and financial difficulties compared with those who did not report either (ORs [CIs]: 2.08 [1.90-2.27] to 29.46 [25.32-34.27]). CONCLUSIONS: Having the combination of mental health problems and financial difficulties is strongly associated with increased risk for social exclusion, far beyond the effect of either factor alone.

Transitioning to a guaranteed annual income and the impact on activities of daily living in older adults: Evidence from public pensions in Canada using the CLSA.

OBJECTIVE: Statistically model the likelihood of changes in the activities of daily living (ADLs) over time for three groups of older adults: those on a pension at all time periods, those never on a pension, and those who transition onto a public pension. METHODS: Our study used data from the Canadian Longitudinal Study on Aging (CLSA), a large national survey. We used data from baseline (2010-2015) and the first follow-up wave (2015-2018). We used logistic regression to model the likelihood of ADL changes in males and females by pension receipt status, controlling for several potential confounders and allowing for the impact of public pensions to be modified by baseline income. RESULTS: The magnitudes of the estimates indicated that those who transition to a public pension are less likely to report ADL degradation and more likely to report ADL improvement compared to those with no public pension. In the lowest baseline income group, those who transitioned onto a pension at follow-up had a 15% (male) or 11% (female) lower likelihood of reporting degraded ADL scores compared to those not receiving a pension at follow-up. Those who transitioned onto a pension in the lowest income group were more likely to report an improved ADL score at follow-up. CONCLUSION: Our results could provide evidence for the potential health benefits of more comprehensive guaranteed annual income programs beyond the pension program. The penalty of being low-income was mitigated by the stability of the pension income in terms of ADL improvement or degradation.

RéSUMé: OBJECTIF: Modeler statistiquement la probabilité de changements des activités de la vie quotidienne (AVQ) à travers le temps pour trois groupes d'adultes âgés : ceux qui reçoivent une pension tout le temps, ceux qui ne reçoivent jamais une pension, et ceux qui transitionnent à recevoir une pension pendant la période d'étude. MéTHODES: Notre étude a utilisé les données de l'Étude longitudinale canadienne sur le vieillissement (ÉLCV), une grande enquête nationale. On a utilisé les données de base (2010-2015) et de la première vague (2015-2018). On a utilisé une régression logistique pour modeler la probabilité de changement des AVQ dans les hommes et les femmes par statut de réception de pension, en ajustant plusieurs facteurs de confusion potentielles et pour que l'impact de pensions publiques soient modifiées par le revenu de base. RéSULTATS: La magnitude des estimations a indiqué que ceux qui font une transition à une pension publique sont moins probables de signaler une dégradation des AVQ et plus probables de déclarer une amélioration comparés à ceux qui ne reçoivent pas une pension publique. Parmi le groupe de revenu de base le plus bas, ceux qui ont transitionné à recevoir une pension au suivi avaient 15 % (hommes) ou 11 % (femmes) moins de chance de déclarer une évaluation de AVQ dégradée comparé à ceux qui ne recevaient pas une pension au suivi. Ceux qui ont transitionné à recevoir une pension dans le groupe de revenu de base le plus bas étaient plus probables de déclarer une évaluation de AVQ améliorée au suivi. CONCLUSION: Nos résultats pourraient apporter la preuve pour les avantages potentiels des programmes compréhensifs de revenu garanti qui vont plus loin que les pensions publiques. La pénalité de faire partie du groupe de revenu le plus bas est atténuée par la stabilité des revenus de pension en ce qui concerne l'amélioration ou la dégradation des AVQ.