Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion.

Importance: The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective: To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants: Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure: Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures: Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results: The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (ß coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance: Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Predicting the drop out from the maternal, newborn and child healthcare continuum in three East African Community countries: application of machine learning models.

BACKGROUND: For optimal health, the maternal, newborn, and child healthcare (MNCH) continuum necessitates that the mother/child receive the full package of antenatal, intrapartum, and postnatal care. In sub-Saharan Africa, dropping out from the MNCH continuum remains a challenge. Using machine learning, the study sought to forecast the MNCH continuum drop out and determine important predictors in three East African Community (EAC) countries. METHODS: The study utilised Demographic Health Surveys data from the Democratic Republic of Congo (DRC) (2013/14), Kenya (2014) and Tanzania (2015/16). STATA 17 was used to perform the multivariate logistic regression. Python 3.0 was used to build five machine learning classification models namely the Logistic Regression, Random Forest, Decision Tree, Support Vector Machine and Artificial Neural Network. Performance of the models was assessed using Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics (AUROC). RESULTS: The prevalence of the drop out from the MNCH continuum was 91.0% in the DRC, 72.4% in Kenya and 93.6% in Tanzania. Living in the rural areas significantly increased the odds of dropping out from the MNCH continuum in the DRC (AOR:1.76;95%CI:1.30-2.38), Kenya (AOR:1.23;95%CI:1.03-1.47) and Tanzania (AOR:1.41;95%CI:1.01-1.97). Lower maternal education also conferred a significant increase in the DRC (AOR:2.16;95%CI:1.67-2.79), Kenya (AOR:1.56;95%CI:1.30-1.84) and Tanzania (AOR:1.70;95%CI:1.24-2.34). Non exposure to mass media also conferred a significant positive influence in the DRC (AOR:1.49;95%CI:1.15-1.95), Kenya (AOR:1.46;95%CI:1.19-1.80) and Tanzania (AOR:1.65;95%CI:1.13-2.40). The Random Forest exhibited superior predictive accuracy (Accuracy = 75.7%, Precision = 79.1%, Recall = 92.1%, Specificity = 51.6%, F1 score = 85.1%, AUROC = 70%). The top four predictors with the greatest influence were household wealth, place of residence, maternal education and exposure to mass media. CONCLUSIONS: The MNCH continuum dropout rate is very high in the EAC countries. Maternal education, place of residence, and mass media exposure were common contributing factors to the drop out from MNCH continuum. The Random Forest had the highest predictive accuracy. Household wealth, place of residence, maternal education and exposure to mass media were ranked among the top four features with significant influence. The findings of this study can be used to support evidence-based decisions in MNCH interventions and to develop web-based services to improve continuity of care retention.

Mental health and sleep quality of low-income mothers of one-year-olds during the COVID-19 pandemic.

The COVID-19 pandemic and subsequent social restrictions created an unprecedented context for families raising young children. Although studies have documented detrimental effects of the pandemic on maternal well-being, less is known about how the pandemic specifically impacted low-income mothers. We examined depression, anxiety, and sleep quality among low-income mothers of one-year-olds during the early months of the pandemic using data from the Baby's First Years study. Focusing on the control group (n = 547), we compared mothers interviewed before March 14th, 2020 (n = 342) to mothers interviewed between March 14th and June 30th, 2020 (n = 205) to determine whether the pandemic was associated with differences in mental health and sleep quality. Mothers were recruited from four cities in the United States, and most of the sample identified as Hispanic (42.2%) or Black, non-Hispanic (38.6%). We found that mothers interviewed during the pandemic reported better mental health and sleep quality. While we cannot speak to longer-term impacts of the pandemic, it is possible low-income mothers experienced relief from daily stressors during the initial shelter-in-place orders, which may have led to improvements in well-being. These results have implications for understanding how complex life stressors influence mental health and sleep quality among low-income mothers raising young children.

La pandemia del COVID-19 y las subsecuentes restricciones sociales crearon un contexto sin precedentes para las familias que estaban criando niños pequeños. Aunque los estudios han documentado los efectos perjudiciales de la pandemia sobre el bienestar materno, menos se conoce acerca de cómo la pandemia específicamente tuvo un impacto sobre madres de bajos recursos económicos. Examinamos la depresión, ansiedad y calidad del sueño entre madres de bajos recursos económicos de niños de un año de edad durante los primeros meses de la pandemia usando datos del estudio Primeros Años del Bebé. Enfocándonos en el grupo de control (n = 547), comparamos las madres entrevistadas antes del 14 de marzo de 2020 (n = 342) con madres entrevistadas entre el 14 de marzo y el 30 de junio de 2020 (n = 205) para determinar si la pandemia se asociaba con diferencias en salud mental y calidad del sueño. A las madres se les reclutó en cuatro ciudades de Estados Unidos y la mayor parte del grupo muestra se identificaron como Hispanas (42.2%) o Negras no Hispanas (38.6%). Encontramos que las madres entrevistadas durante la pandemia reportaron mejor salud mental y calidad del sueño. A pesar de que no podemos hablar sobre el impacto a largo plazo de la pandemia, es posible que las madres de bajos recursos económicos experimentaran alivio en los factores diarios de estrés durante el inicial mandato de quedarse en su casa, lo cual pudiera haber llevado a mejoras en el bienestar. Estos resultados tienen implicaciones para comprender cómo los complejos factores de estrés influyen en la salud mental y la calidad del sueño entre madres de bajos recursos económicos que crían a niños pequeños.

La pandémie du COVID-19 et les restrictions sociales qui en ont découlé ont créé un contexte sans précédent pour les familles élevant de jeunes enfants. Bien que des études aient documenté des effets préjudiciables de la pandémie sur le bien-être maternel, on en sait moins sur la manière dont la pandémie a spécifiquement impacté les mères de milieux défavorisés. Nous avons examiné la dépression, l'anxiété, et la qualité du sommeil chez des mères de milieux défavorisés avec un enfant d'un an durant les premiers mois de la pandémie, en utilisant des données de l'étude Baby's First Years. Nous concentrant sur le groupe de contrôle (n = 547), nous avons comparé des mères interviewées avant le 14 mars 2020 (n = 342) à des mères interviewées entre le 14 mars et le 30 juin 2020 (n = 205) afin de déterminer si la pandémie était liée à des différences en santé mentale et en qualité de sommeil. Les mères ont été recrutées dans quatre villes des Etats-Unis et la plupart de l'échantillon s'identifiait comme Hispanique (42,2%) ou Noires, non hispaniques (38,6%). Nous avons trouvé que les mères interviewées Durant la pandémie faisaient état d'une meilleure santé mentale et d'une meilleure qualité de sommeil. Bien que nous ne puissions pas parler des impacts de la pandémie à long terme, il est possible que les mères de milieux défavorisés aient fait l'expérience d'un soulagement des facteurs de stress quotidiens durant la période initiale de confinement, ce qui pourrait avoir mené à des améliorations dans le bien-être. Ces résultats ont des implications pour la compréhension de la manière dont des facteurs de stress complexes influencent la santé mentale et la qualité du sommeil chez les mères de milieux défavorisés élevant de jeunes enfants.

Multifaceted risk for non-suicidal self-injury only versus suicide attempt in a population-based cohort of adults.

BACKGROUND: Non-suicidal self-injury and suicide attempt represent significant public health concerns. While these outcomes are related, there is prior evidence that their etiology does not entirely overlap. Efforts to directly differentiate risk across outcomes are uncommon, particularly among older, population-based cohorts. METHODS: This research has been conducted using the UK Biobank. Data on individuals' self-reported history of non-suicidal self-injury only versus suicide attempt (maximum N = 6643) were analyzed. Applying LASSO and standard logistic regression, participants reporting one of these outcomes were assessed for differences across a range of sociodemographic, behavioral, and environmental features. RESULTS: Sociodemographic features most strongly differentiated between the outcomes of non-suicidal self-injury only versus suicide attempt. Specifically, Black individuals were more likely to report a suicide attempt, as were those of mixed race, those endorsing higher levels of depressive symptoms or trauma history, and those who had experienced financial problems (odds ratios 1.02-3.92). Those more likely to engage in non-suicidal self-injury only were younger, female, had higher levels of education, those who resided with a partner, and those who had a recently injured relative. LIMITATIONS: Differences in timing across correlates and outcomes preclude the ability to establish causal pathways. CONCLUSIONS: The factors identified in the current study as differentially associated with non-suicidal self-injury only versus suicide attempt provide further evidence of at least partially distinct correlates, and warrant follow-up in independent samples to investigate causality.

Wealth and Sedentary Time Are Associated With Dietary Patterns Among Preadolescents in Nairobi City, Kenya.

OBJECTIVE: The study aimed to compare dietary patterns in preadolescents in urban areas with different physical activity and socioeconomic profiles in Nairobi, Kenya. DESIGN: Cross-sectional. PARTICIPANTS: Preadolescents aged 9-14 years (n = 149) living in low- or middle-income areas in Nairobi. VARIABLES MEASURED: Sociodemographic characteristics were collected using a validated questionnaire. Weight and height were measured. Diet was assessed using a food frequency questionnaire and physical activity by accelerometer. ANALYSIS: Dietary patterns (DP) were formed through principal component analysis. Associations of age, sex, parental education, wealth, body mass index, physical activity, and sedentary time with DPs were analyzed with linear regression. RESULTS: Three DPs explained 36% of the total variance in food consumption: (1) snacks, fast food, and meat; (2) dairy products and plant protein; and (3) vegetables and refined grains. Higher wealth was associated with higher scores of the first DP (P < 0.05). CONCLUSIONS AND IMPLICATIONS: Consumption of foods often deemed unhealthy (eg, snacks and fast food) was more frequent among preadolescents whose families were wealthier. Interventions that seek ways to promote healthy lifestyles among families residing in urban areas of Kenya are warranted.

Association of childhood threat and deprivation with depressive symptoms and the moderating role of current economic status among middle-aged and older adults in China.

PURPOSE: To investigate the independent impact of threat-related and deprivation-related adverse childhood experiences (ACEs) on depressive symptoms among middle-aged and older adults, and to evaluate the moderating role of current economic status in these associations. METHODS: This cross-sectional study included 11,048 participants aged ≥ 45 years from the China Health and Retirement Longitudinal Study. We captured five threat-related ACEs and five deprivation-related ACEs by questionnaires. Depressive symptoms were assessed using the 10-item Centre for Epidemiological Studies Depression Scale. Current economic status was reflected by annual per capita household consumption expenditure. We performed logistic regression analyses to evaluate the independent association of childhood threat and deprivation with depressive symptoms, and conducted stratified analyses and tests for interaction to explore the moderation effect of current economic status in such associations. RESULTS: Compared with the nonexposed group, the experience of both childhood threat and deprivation were independently associated with greater risks of depressive symptoms later in life (odds ratio [OR] 1.75, 95% CI 1.49-2.05 for ≥ 2 threat-related ACEs; OR 2.02, 95% CI 1.67-2.43 for ≥ 2 deprivation-related ACEs). High current economic status significantly ameliorated the impact of childhood deprivation, but not threat, on depressive symptoms (P value for interaction 0.038). CONCLUSIONS: Both threat-related and deprivation-related ACEs were associated with the risk of depressive symptoms among middle-aged and older adults, while current economic status was a significant moderator in such risks only for childhood deprivation. The findings implied that prioritising targeted interventions for individuals with ACEs, especially for childhood deprivation victims who were economically disadvantaged in adulthood, may help mitigate depressive symptoms in later life.

Social capital I: measurement and associations with economic mobility.

Social capital-the strength of an individual's social network and community-has been identified as a potential determinant of outcomes ranging from education to health1-8. However, efforts to understand what types of social capital matter for these outcomes have been hindered by a lack of social network data. Here, in the first of a pair of papers9, we use data on 21 billion friendships from Facebook to study social capital. We measure and analyse three types of social capital by ZIP (postal) code in the United States: (1) connectedness between different types of people, such as those with low versus high socioeconomic status (SES); (2) social cohesion, such as the extent of cliques in friendship networks; and (3) civic engagement, such as rates of volunteering. These measures vary substantially across areas, but are not highly correlated with each other. We demonstrate the importance of distinguishing these forms of social capital by analysing their associations with economic mobility across areas. The share of high-SES friends among individuals with low SES-which we term economic connectedness-is among the strongest predictors of upward income mobility identified to date10,11. Other social capital measures are not strongly associated with economic mobility. If children with low-SES parents were to grow up in counties with economic connectedness comparable to that of the average child with high-SES parents, their incomes in adulthood would increase by 20% on average. Differences in economic connectedness can explain well-known relationships between upward income mobility and racial segregation, poverty rates, and inequality12-14. To support further research and policy interventions, we publicly release privacy-protected statistics on social capital by ZIP code at https://www.socialcapital.org .

Social capital II: determinants of economic connectedness.

Low levels of social interaction across class lines have generated widespread concern1-4 and are associated with worse outcomes, such as lower rates of upward income mobility4-7. Here we analyse the determinants of cross-class interaction using data from Facebook, building on the analysis in our companion paper7. We show that about half of the social disconnection across socioeconomic lines-measured as the difference in the share of high-socioeconomic status (SES) friends between people with low and high SES-is explained by differences in exposure to people with high SES in groups such as schools and religious organizations. The other half is explained by friending bias-the tendency for people with low SES to befriend people with high SES at lower rates even conditional on exposure. Friending bias is shaped by the structure of the groups in which people interact. For example, friending bias is higher in larger and more diverse groups and lower in religious organizations than in schools and workplaces. Distinguishing exposure from friending bias is helpful for identifying interventions to increase cross-SES friendships (economic connectedness). Using fluctuations in the share of students with high SES across high school cohorts, we show that increases in high-SES exposure lead low-SES people to form more friendships with high-SES people in schools that exhibit low levels of friending bias. Thus, socioeconomic integration can increase economic connectedness in communities in which friending bias is low. By contrast, when friending bias is high, increasing cross-SES interactions among existing members may be necessary to increase economic connectedness. To support such efforts, we release privacy-protected statistics on economic connectedness, exposure and friending bias for each ZIP (postal) code, high school and college in the United States at https://www.socialcapital.org .

Changes in the Relationship Between Income and Life Expectancy Before and During the COVID-19 Pandemic, California, 2015-2021.

Importance: The COVID-19 pandemic caused a large decrease in US life expectancy in 2020, but whether a similar decrease occurred in 2021 and whether the relationship between income and life expectancy intensified during the pandemic are unclear. Objective: To measure changes in life expectancy in 2020 and 2021 and the relationship between income and life expectancy by race and ethnicity. Design, Setting, and Participants: Retrospective ecological analysis of deaths in California in 2015 to 2021 to calculate state- and census tract-level life expectancy. Tracts were grouped by median household income (MHI), obtained from the American Community Survey, and the slope of the life expectancy-income gradient was compared by year and by racial and ethnic composition. Exposures: California in 2015 to 2019 (before the COVID-19 pandemic) and 2020 to 2021 (during the COVID-19 pandemic). Main Outcomes and Measures: Life expectancy at birth. Results: California experienced 1 988 606 deaths during 2015 to 2021, including 654 887 in 2020 to 2021. State life expectancy declined from 81.40 years in 2019 to 79.20 years in 2020 and 78.37 years in 2021. MHI data were available for 7962 of 8057 census tracts (98.8%; n = 1 899 065 deaths). Mean MHI ranged from $21 279 to $232 261 between the lowest and highest percentiles. The slope of the relationship between life expectancy and MHI increased significantly, from 0.075 (95% CI, 0.07-0.08) years per percentile in 2019 to 0.103 (95% CI, 0.098-0.108; P < .001) years per percentile in 2020 and 0.107 (95% CI, 0.102-0.112; P < .001) years per percentile in 2021. The gap in life expectancy between the richest and poorest percentiles increased from 11.52 years in 2019 to 14.67 years in 2020 and 15.51 years in 2021. Among Hispanic and non-Hispanic Asian, Black, and White populations, life expectancy declined 5.74 years among the Hispanic population, 3.04 years among the non-Hispanic Asian population, 3.84 years among the non-Hispanic Black population, and 1.90 years among the non-Hispanic White population between 2019 and 2021. The income-life expectancy gradient in these groups increased significantly between 2019 and 2020 (0.038 [95% CI, 0.030-0.045; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI: 0.005-0.044; P = .02] years per percentile among Asian individuals; 0.015 [95% CI, 0.010-0.020; P < .001] years per percentile among Black individuals; and 0.011 [95% CI, 0.007-0.015; P < .001] years per percentile among White individuals) and between 2019 and 2021 (0.033 [95% CI, 0.026-0.040; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI, 0.010-0.038; P = .002] years among Asian individuals; 0.024 [95% CI, 0.011-0.037; P = .003] years per percentile among Black individuals; and 0.013 [95% CI, 0.008-0.018; P < .001] years per percentile among White individuals). The increase in the gradient was significantly greater among Hispanic vs White populations in 2020 and 2021 (P < .001 in both years) and among Black vs White populations in 2021 (P = .04). Conclusions and Relevance: This retrospective analysis of census tract-level income and mortality data in California from 2015 to 2021 demonstrated a decrease in life expectancy in both 2020 and 2021 and an increase in the life expectancy gap by income level relative to the prepandemic period that disproportionately affected some racial and ethnic minority populations. Inferences at the individual level are limited by the ecological nature of the study, and the generalizability of the findings outside of California are unknown.

Racial, Ethnic, and Socioeconomic Disparities in Access to Transcatheter Aortic Valve Replacement Within Major Metropolitan Areas.

Importance: Despite the benefits of high-technology therapeutics, inequitable access to these technologies may generate disparities in care. Objective: To examine the association between zip code-level racial, ethnic, and socioeconomic composition and rates of transcatheter aortic valve replacement (TAVR) among Medicare patients living within large metropolitan areas with TAVR programs. Design, Setting, and Participants: This multicenter, nationwide cross-sectional analysis of Medicare claims data between January 1, 2012, and December 31, 2018, included beneficiaries of fee-for-service Medicare who were 66 years or older living in the 25 largest metropolitan core-based statistical areas. Exposure: Receipt of TAVR. Main Outcomes and Measures: The association between zip code-level racial, ethnic, and socioeconomic composition and rates of TAVR per 100 000 Medicare beneficiaries. Results: Within the studied metropolitan areas, there were 7590 individual zip codes. The mean (SD) age of Medicare beneficiaries within these areas was 71.4 (2.0) years, a mean (SD) of 47.6% (5.8%) of beneficiaries were men, and a mean (SD) of 4.0% (7.0%) were Asian, 11.1% (18.9%) were Black, 8.0% (12.9%) were Hispanic, and 73.8% (24.9%) were White. The mean number of TAVRs per 100 000 Medicare beneficiaries by zip code was 249 (IQR, 0-429). For each $1000 decrease in median household income, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.2% (95% CI, 0.1%-0.4%) lower (P = .002). For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 2.1% (95% CI, 1.3%-2.9%) lower (P < .001). For each 1-unit increase in the Distressed Communities Index score, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.4% (95% CI, 0.2%-0.5%) lower (P < .001). Rates of TAVR were lower in zip codes with higher proportions of patients of Black race and Hispanic ethnicity, despite adjusting for socioeconomic markers, age, and clinical comorbidities. Conclusions and Relevance: Within major metropolitan areas in the US with TAVR programs, zip codes with higher proportions of Black and Hispanic patients and those with greater socioeconomic disadvantages had lower rates of TAVR, adjusting for age and clinical comorbidities. Whether this reflects a different burden of symptomatic aortic stenosis by race and socioeconomic status or disparities in use of TAVR requires further study.

Determinants of birthplace among middle-to lower-class women in Indonesia: A study using the Indonesian Demographic and Health Survey.

BACKGROUND: One of the factors contributing to a high maternal mortality rate is the utilization of non-healthcare facilities as a birthplace for women. This study analyzed determinants affecting birthplace in middle-to lower-class women in Indonesia. METHODS: This study analyzed the 2017 Indonesian Demographic and Health Survey (IDHS) data. The total national sample size was 49,627 eligible women. Our sample included 11,104 women, aged 15-49, who had delivered babies and were of low-to-middle economic status. The type of survey dataset was individual record dataset. Data were analyzed with chi-square and multivariate logistic regression tests using Stata 16 software. RESULTS: About 64.99% middle to lower class women in Indonesia delivered in healthcare facilities. Women aged 45-49 (OR = 2.103; 95% CI = 1.13-3.93), who graduated from higher schools (OR = 2.885; 95% CI = 1.76-4.73), whose husbands had higher education (OR = 2.826; 95% CI = 1.69-4.74) and were employed (OR = 2.523; 95% CI = 1.23-5.17), who considered access to healthcare facilities was not a problem (OR = 1.528; 95% CI = 1.28-1.82), who had a single child (OR = 2.349; 95% CI = 1.97-2.80), and who lived in urban areas (OR = 2.930; 95% CI = 2.40-3.57) were determinants that significantly correlated with women giving birth in healthcare facilities. CONCLUSION: This study provides insights for policymakers and healthcare centers in the community to strengthen access to healthcare services and devise health promotion strategies for pregnant mothers. Policy interventions designed for middle- to lower-class women should be implemented to support vulnerable groups.

The negative consequences of sports betting opportunities on human capital formation: Evidence from Spain.

The proliferation of on-site betting shops has received enormous public attention, becoming one of the most alarming health policy issues in contemporary cities. However, there is little evidence on whether its growing presence nearby vulnerable populations produce social harm beyond its known adverse individual effects. This study provides new evidence on the negative societal effects of betting houses. Our research design takes advantage of a new wave of openings in Madrid (Spain), which created a sudden increase in the supply of on-site gambling. Using a differences-in-differences design, we find that new betting houses decline nearby high schools' educational performance, especially in public schools in less advantaged areas. This effect is neither trivial nor diminishing with time. This evidence suggests that betting houses increase inequality of educational opportunities. The ubiquity of betting houses around vulnerable populations in multiple regions drives us to think that these findings have relevant policy implications for many countries currently designing policies tackling the increase of problem gambling.

Welfare states as lifecycle redistribution machines: Decomposing the roles of age and socio-economic status shows that European tax-and-benefit systems primarily redistribute across age groups.

Social scientists identify two core functions of modern welfare states as redistribution across (a) socio-economic status groups (Robin Hood) and (b) 'the lifecycle' (the piggy bank). But what is the relative importance of these functions? The answer has been elusive, as the piggy bank is metaphorical. The intra-personal time-travel of resources it implies is based on non-quid-pro-quo transfers. In practice, 'lifecycle redistribution' must operate through inter-age-group resource reallocation in cross-section. Since at any time different birth cohorts live together, 'resource-productive' working-aged people are taxed to finance consumption of 'resource-dependent' younger and older people. In a novel decomposition analysis, we study the joint distribution of socio-economic status, age, and respectively (a) all cash and in-kind transfers ('benefits'), (b) financing contributions ('taxes'), and (c) resulting 'net benefits,' on a sample of over 400,000 Europeans from 22 EU countries. European welfare states, often maligned as ineffective Robin Hood vehicles riddled with Matthew effects, are better characterized as inter-age redistribution machines performing a more important second task rather well: lifecycle consumption smoothing. Social policies serve multiple goals in Europe, but empirically they are neither primarily nor solely responsible for poverty relief and inequality reduction.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income.

INTRODUCTION: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Curvilinear associations between family income in early childhood and the cortisol awakening response in adolescence.

Previous evidence on cortisol output and socioeconomic status (SES) has been mixed, with studies finding that lower SES can be associated with higher or lower cortisol output, and null associations have also been reported. We hypothesized that these inconsistencies may be due to an underlying curvilinear, inverted-U pattern of association, such that low income is related to increased likelihood of both low and high cortisol output. We tested these curvilinear links among family income and cortisol indices in the Avon Longitudinal Study of Parents and Children (N = 803). Maternal reports of family income when the study children were 33 and 47 months of age were averaged to estimate early-childhood family income. Three cortisol indices were derived from samples collected in adolescence (15.5 years of age): the cortisol awakening response (CAR), area under the curve (AUC) cortisol, and the diurnal cortisol slope. As hypothesized, the CAR exhibited a curvilinear, inverted-U relation with childhood income, with low childhood income being associated with both the lowest and the highest CARs. These findings suggest that discrepancies in prior findings on low SES and the CAR may be due to curvilinear patterns of association. However, childhood income was not significantly associated with adolescent cortisol diurnal slope or AUC. Future work should clarify the factors that might predispose to high versus low CAR given equivalent low SES in childhood.

Persons With Debt Burden Are More Likely to Report Suicide Attempt Than Those Without: A National Study of US Adults.

OBJECTIVE: To assess the association between debt burden and self-reported suicide attempt among US adults. METHODS: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) were used to estimate the association between self-reported past-year debt burden and past-year and lifetime suicide attempt with logistic regression, controlling for sociodemographic characteristics with known associations with debt burden and suicide attempt. RESULTS: Among 36,278 adults aged ≥ 18 years, 13.03% reported past-year debt burden, 0.37% reported past-year suicide attempt, and 5.16% reported lifetime suicide attempt. Self-reported attempt was more likely for persons reporting debt burden than for those without (eg, for past-year suicide attempt: odds ratio [OR] = 7.96 [95% CI, 5.45-11.64; P < .001] when unadjusted; OR = 3.39 [95% CI, 2.15-5.34; P < .001] when adjusted for sociodemographic variables and mood disorders). The adjusted prevalence of past-year suicide attempt for those with and without debt burden was 0.75% (95% CI, 0.50%-1.00%) and 0.23% (95% CI, 0.17%-0.29%), respectively. CONCLUSIONS: Debt burden is strongly associated with increased likelihood of suicide attempt. The strength of the identified association is comparable to or greater than that for other major predictors of suicide (eg, sex) and other mortality risk factors (eg, smoking, obesity). Findings highlight debt burden as a strong social determinant of suicide risk and intervention target.

Factors influencing place of delivery: Evidence from three south-Asian countries.

BACKGROUND: High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries. METHODS: We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted. RESULTS: Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041). CONCLUSION: Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.

The socio-economic status of families experiencing the sudden unexpected death of an infant - Is it possibly related to a higher rate of non-natural deaths among them.

Low socio-economic status is recognized as one of the risk factors for SIDS. In this study we have pointed out the similarities between families that have SIDS cases and families in which infant non-accidental injury has been proven, as well as the differences between them and the general population. This study was conducted in Montenegro, comparing 30 cases of SIDS with 25 cases of known infanticides and with a control group (60 cases) consisting of live newborns and their mothers from the general population, randomly selected from hospital-born newborns without exclusion criteria. We combined and compared the infant characteristics and mother characteristics between the above cases. There were significant similarities between the SIDS group and the infanticide group in terms of the following characteristics: the education level of the mothers (p = 0.086); maternal employment (p = 0.278); and place of residence (p = 0.269); while there were differences between the two groups regarding hospital birth (p = 0.027) and marital status (p = 0.011). The SIDS and infanticide groups, combined, had higher incidences of: out-of-hospital deliveries (p < 0.001); uneducated mothers (p < 0.001); unemployed mothers (p < 0.001); low socio-economic status (p < 0.001); and cases outside of marriage (p < 0.001), compared to the control groups. This study indicated a possible higher incidence of non-natural death among SIDS cases, as reflected by low socio-economic status and linked attributes, which is explained by their similarities with the infanticide groups and differences with the control groups.