Does the state you live in make a difference? Multilevel analysis of self-rated health in the US

The differential impacts of COVID-19 mortality on mental health by residential geographic regions: The Los Angeles Pandemic Surveillance Cohort Study

OBJECTIVE

This study examines the association between changes in mental health before and during the COVID-19 pandemic and COVID-19 mortality across geographic areas and by race/ethnicity.

METHODS

A cross-sectional survey was conducted in Los Angeles County between April and May 2021. The study used the Patient Health Questionnaire-2 to assess major depression risk. Participants' home ZIP codes were classified into low, middle, and high COVID-19 mortality impacted areas (CMIA).

RESULTS

While there were existing mental health disparities due to differences in demographics and social determinants of health across CMIA in 2018, the pandemic exacerbated the disparities, especially for residents living in high CMIA. Non-White residents in high CMIA reported the largest deterioration in mental health. Differences in mental health by CMIA persisted after controlling for resident characteristics.

CONCLUSIONS

Living in an area with higher COVID-19 mortality rates may have been associated with worse mental health, with Non-White residents reporting worse mental health outcomes in the high mortality area.

POLICY IMPLICATIONS

It is crucial to advocate for greater mental health resources in high COVID-19 mortality areas especially for racial/ethnic minorities.

The Association Between State Characteristics and Latinx People's Treated Hypertension in Established and New Latinx Destination States: A Multilevel Analysis

This study sought to quantify the contributions of state-level factors including income inequality, state's legislature political control, and Medicaid expansion in new and established Latinx destination states on Latinx individuals' treated hypertension. Mixed-effects logistic regression analyses were conducted to analyze 2017 Behavioral Risk Factor Surveillance System data from 7524 Latinx adults nested within 39 states. Overall, 70% reported being pharmacologically treated for hypertension, and 66% resided in established destination states. Compared with Latinx people in established destination states, Latinx people in new destinations had lower odds of having treated hypertension (odds ratio [OR] = 0.72, 95% CI = 0.54-0.95). Within established Latinx destinations, the odds of treated hypertension were lower in states where legislatures expanded Medicaid than in states that did not expand Medicaid (OR = 0.84, 95% CI = 0.79-0.89). However, after controlling for the effects of individual-level factors, this association was no longer statistically significant. In new Latinx destination states, Medicaid expansion, legislatures' political control, and income inequality were not associated with treated hypertension. The study results highlight the importance of considering both individual- and state-level factors, as the interplay of such factors could hinder the successful implementation of cardiovascular risk reduction interventions.

How economic development affects healthcare access for people with disabilities: A multilevel study in China

Meeting the healthcare needs of people with disabilities is an important challenge in achieving the central promise of "leave no one behind" during the Sustainable Development Goals era. In this study, we describe the accessibility of healthcare for people living with disabilities, as well as the potential influences of individuals' socioeconomic status and regional economic development. Our data covered 324 prefectural cities in China in 2019 and captured the access to healthcare services for people with disabilities. First, we used linear probability regression models to investigate the association between individual socioeconomic status, including residence, poverty status, education, and healthcare access. Second, we conducted an ecological analysis to test the association between prefectural economic indicators, including GDP (gross domestic product) per capita, urbanization ratio, average years of education, Engel's coefficient, and the overall prevalence of access to healthcare for people with disabilities within prefectures. Third, we used multilevel regression models to explore the association between the individual's socio-economic status, prefectural economic indicators, and access to healthcare at the individual level for people with disabilities. The results showed, first, that higher individual socioeconomic status (urban residence or higher educational level) was associated with better access to healthcare for people with disabilities. Second, regional economic indicators were positively associated with access to healthcare at the aggregate and individual levels. This study suggests that local governments, particularly in low- and middle-income countries, should promote economic development and conduct poverty alleviation policies to improve healthcare access for disadvantaged groups.

Causal Assessment of Income Inequality on Self-Rated Health and All-Cause Mortality: A Systematic Review and Meta-Analysis

Policy Points Income is thought to impact a broad range of health outcomes. However, whether income inequality (how unequal the distribution of income is in a population) has an additional impact on health is extensively debated. Studies that use multilevel data, which have recently increased in popularity, are necessary to separate the contextual effects of income inequality on health from the effects of individual income on health. Our systematic review found only small associations between income inequality and poor self-rated health and all-cause mortality. The available evidence does not suggest causality, although it remains methodologically flawed and limited, with very few studies using natural experimental approaches or examining income inequality at the national level.

CONTEXT

Whether income inequality has a direct effect on health or is only associated because of the effect of individual income has long been debated. We aimed to understand the association between income inequality and self-rated health (SRH) and all-cause mortality (mortality) and assess if these relationships are likely to be causal.

METHODS

We searched Medline, ISI Web of Science, Embase, and EconLit (PROSPERO: CRD42021252791) for studies considering income inequality and SRH or mortality using multilevel data and adjusting for individual-level socioeconomic position. We calculated pooled odds ratios (ORs) for poor SRH and relative risk ratios (RRs) for mortality from random-effects meta-analyses. We critically appraised included studies using the Risk of Bias in Nonrandomized Studies - of Interventions tool. We assessed certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework and causality using Bradford Hill (BH) viewpoints.

FINDINGS

The primary meta-analyses included 2,916,576 participants in 38 cross-sectional studies assessing SRH and 10,727,470 participants in 14 cohort studies of mortality. Per 0.05-unit increase in the Gini coefficient, a measure of income inequality, the ORs and RRs (95% confidence intervals) for SRH and mortality were 1.06 (1.03-1.08) and 1.02 (1.00-1.04), respectively. A total of 63.2% of SRH and 50.0% of mortality studies were at serious risk of bias (RoB), resulting in very low and low certainty ratings, respectively. For SRH and mortality, we did not identify relevant evidence to assess the specificity or, for SRH only, the experiment BH viewpoints; evidence for strength of association and dose-response gradient was inconclusive because of the high RoB; we found evidence in support of temporality and plausibility.

CONCLUSIONS

Increased income inequality is only marginally associated with SRH and mortality, but the current evidence base is too methodologically limited to support a causal relationship. To address the gaps we identified, future research should focus on income inequality measured at the national level and addressing confounding with natural experiment approaches.

The association between food insecurity and social capital under the lockdowns in COVID-hit Shanghai

As an emergency, food insecurity threatens people’s well-being, while social capital is expected to enhance their resilience in this situation. This study examined the relationship between food insecurity and social capital during the COVID-19 lockdowns in Shanghai. We collected a dataset of 1064 participants by random sampling. Structural equation modelling was used to analyse the dynamics of social capital before and after lockdowns. The results show that the level of post-lockdown social capital was higher than that of pre-lockdown social capital. Pre-lockdown social capital predicted the extent to which people suffered from food insecurity and their approaches to obtaining food. Participation in group purchases and food exchange with other residents predicted the levels of post-lockdown social capital. The results shed light on the interaction between emergencies and social capital. Our study theoretically contributes to understanding social capital through a dynamic perspective.

Income Inequality, Race/Ethnicity, and Obesity in U.S. Men 20 Years and Older: 1999 to 2016

Obesity is a significant public health problem globally and within the United States. It varies by multiple factors, including but not limited to income. The literature indicates little evidence of the association between income and obesity. We examined the association between income and obesity in U.S. adult men ages 20 years and older and tested racial and ethnic differences. We used data from the 1999 to 2016 National Health and Nutrition Examination Surveys for analyses. Obesity was determined using body mass index ≥30 kg/m2. We used poverty income ratio (PIR) as a proxy for income and calculated the Gini coefficient (GC) to measure income inequality. We then categorized low-, medium-, and high PIR to examine the relationship between income inequality and obesity. We used Modified Poisson regression in a sample of 17,238 adult men, including 9,511 White Non-Hispanic White (NHW), 4,166 Non-Hispanic Black (NHB), and 3,561 Mexican Americans (MA). We controlled the models for age category, racial and ethnic groups, marital status, education, health behaviors, health insurance coverage, self-reported health, comorbidity, and household structure. Results of our adjusted models suggested a positive and significant association between PIR and obesity among NHWs and NHBs in medium and high PIR; this association was not significant in MAs. Results of our analyses using GC in obese men indicate that compared with NHWs (GC: 0.306, SE: 0.004), MAs (GC: 0.368, SE: 0.005), and NHBs (GC: 0.328, SE: 0.005) had experienced higher-income inequality. In treating obesity, policymakers should consider race/ethnicity strategies to reduce inequality in income.

Neighborhood disadvantage, health status, and health care utilization after blood or marrow transplant: BMTSS report

Living in a disadvantaged neighborhood is associated with poor health outcomes. Blood or Marrow Transplant (BMT) survivors remain at risk of chronic health conditions requiring anticipatory management. We hypothesized that among BMT survivors, neighborhood disadvantage was associated with poor self-reported routine health care utilization and health. We leveraged data from BMTSS - a retrospective cohort study examining long-term outcomes among individuals surviving ≥2 y following BMT at three institutions between 1974 and 2014. Participants in this analysis completed the BMTSS survey (sociodemographics; chronic health conditions; time since routine check-up; self-reported health). The Area Deprivation Index (ADI) represented neighborhood disadvantage; this composite indicator of 17 census measures is a percentile rank (0 = least deprived to 100 = most deprived). Multivariable ordered logit regression adjusted for clinical factors and individual-level sociodemographics, modeling associations between ADI, time since routine check-up, and self-reported health. Among 2,857 survivors, median ADI was 24 (interquartile range: 10-46). Adjusting for self-reported individual-level socioeconomic indicators and chronic health conditions, patients in more disadvantaged neighborhoods had higher odds of reporting longer intervals since routine check-up (ORADI_continuous = 1.007, P < .001) and poorer health status (controlling for time since check-up; ORADI_continuous = 1.005, P = .003). Compared with patients living in the least disadvantaged neighborhood (ADI = 1), patients in the most disadvantaged neighborhood (ADI = 100), had twice the odds (ORADI = 1.007^99 = 2.06) of reporting no routine visits and 1.65-times the odds of reporting poor health (ORADI = 1.005^99 = 1.65). In BMT survivors, access to health care and health status are associated with area disadvantage. These findings may inform strategies to address long-term care coordination and retention for vulnerable survivors.

Study on the Impact of Income Gap on Health Level of Rural Residents in China

With the rapid development of the social economy, health has increasingly become the focus of attention. Therefore, based on the balanced panel data of the China Household Tracking Survey (CFPS) from 2010 to 2018, the Probit model was used to investigate the impact of the income gap in rural areas on residents' health level, and the relevant influencing mechanism was discussed in this paper. Results: (1) The income gap has a significant negative effect on the health level of rural residents, and the expansion of the income gap will have a more significant impact on the health level of rural residents. (2) The income gap will restrain the health level of rural residents by affecting the family income level and mobility constraints. (3) The restraining effect of the income gap on health formation mainly affects the families of young rural residents, rural male residents, residents with no rental income, and residents with low social capital. This paper analyzes and discusses, from the perspective of income gap, the impact of the income gap on the health status of rural residents in China. Based on the above conclusions, this paper puts forward some feasible suggestions to improve the health level of rural residents.

Social Capital as a Mediator and Moderator in the Association between Loneliness and Health, Israel as a Case Study

Loneliness has been associated with poor health. Social capital (SC) could possibly prevent the ill effects of loneliness. The study aims to assess the association of loneliness with physical and mental health in four different communities in Israel and study the impact of structural and cognitive SC on that association. A cross-sectional face-to-face survey with 4620 adults in four towns was conducted. The questionnaire included self-rated health (SRH), mental health (MH), loneliness, cognitive and structural SC and socioeconomic characteristics. Logistic regression analysis and mediation and moderation effects were calculated. Loneliness was associated with worse SRH (OR = 0.4–0.5) and worse MH (OR = 2.0–10). Both SC variables were associated with health. However, towns differ in these associations. Structural SC serves as a significant mediator between loneliness and SRH in all towns and is a mediator between loneliness and MH in two towns. Cognitive social capital was a moderator between loneliness and MH in two towns. This study suggests that increasing SC could possibly compensate for loneliness and buffer its effect on health. The study reinforces the need for the performance of separate health profiles to assess possible interventions for each community, as not always can we generalize these results to all communities.

State-level political partisanship strongly correlates with health outcomes for US children

The Cook Partisan Voting Index (PVI) determines how strongly a state leans toward the Democratic or Republican Party in US presidential elections compared to the nation. We set out to determine the correlation between childhood health outcomes and state-level partisanship using PVI. Sixteen measures of childhood health were obtained from several US governmental agencies for 2003-2017. The median PVI for every state was calculated for the same time period. Pearson's rho determined the correlation between PVI and each health outcome. Multiple regression was also conducted, adjusting for educational attainment and percentage of non-White residents. We also compared childhood health in moderately Democratic and Republican states (5-9.9% more Democratic/Republican than the national mean) and, similarly, for extremely Democratic and Republican states (10% or more Democratic/Republican than the national mean), using Wilcoxon tests. For all 16 health measures, the median values in Democratic-leaning states represented better outcomes than Republican-leaning states (9/16 had a beta value for linear regression associated with P < 0.05). When compared to Republican states, the median values in moderately Democratic states represented better outcomes for 14 of 16 health measures (9/14 associated with P < 0.05). Similarly, the median values for extremely Democratic states represented better outcomes with regard to all 16 health measures, when compared to Republican-leaning states (8/16 associated with P < 0.05).Conclusions: Democratic-leaning states displayed superior outcomes for multiple childhood health measures when compared to Republican counterpart states. Future research should investigate the significance of these findings and attempt to determine which state-level policies may have contributed to such disparate health outcomes. What is Known: • In the United States, many health disparities exist among children along racial, economic and geographic lines. • Many US states lean strongly towards either the Democratic or Republican political parties in federal elections. What is New: • Trends for multiple measures of childhood health vary in association with the political partisanship of the state being examined. • Multiple barometers of childhood health are superior in Democratic-leaning states, while no measures are better in Republican-leaning states.

Understanding the Interactions of Happiness, Self-Rated Health, Mental Feelings, Habit of Eating Healthy and Sport/Activities: A Path Model for Abu Dhabi

Understanding the interactions between happiness, self-perception of health, healthy eating behaviors, physical activities, and psychological feelings or symptoms of mental health provides necessary inputs for social policymaking. Using data from the second cycle of the Abu Dhabi Quality of Life survey, this study examined a path analysis of Abu Dhabi residents’ nature of assimilations between these variables. The results point to the significant association between happiness and self-rated health. In addition, the results portray significant direct paths to happiness from three mental feeling variables—“feeling calm and peaceful”, “having lots of energy”, and “feeling downhearted and depressed”. The variable of “often feeling rushed or pressed for time” shows a direct path to self-rated health only. Eating healthy food is significantly associated with both happiness and self-perception of health. In addition, “often doing physical activities” positively influences happiness. The present study enhances and refines policymakers’ understanding of the considered factors on happiness and self-rated health with further elaborations of the mediating roles of specific well-being determinants. Limitations and future research directions are also discussed.

From convergence to divergence: Lifespan variation in US states, 1959-2017

BACKGROUND

Large disparities in life expectancy exist across US states and the gaps have been widening in recent decades. Less is known about the lifespan variability - a measure that can provide important insights into mortality inequalities both between and within states.

METHOD

Using yearly lifetables from the United States Mortality Database, we explore geographic and temporal patterns in lifespan variation (unconditional and conditional on survival to age 10, 35 and 65) across US states between 1959 and 2017. We also examine the contribution of state differences in life expectancy to overall lifespan variation using standard decomposition techniques.

RESULTS

Despite overall convergence in lifespan variation across states over the last six decades, in more recent years there has been notable divergence. Gender-specific analyses show that lifespan variation was generally greater among males than among females; but this pattern reverses for mortality past age 65. Much of the state disparities in lifespan variation, unconditional and conditional on survival to age 10 and 35, were due to mortality differences under the age 65. Decomposition analysis shows that while within-state variability remains the primary driver of overall lifespan variation, the contribution of cross-state differences in life expectancy is growing.

CONCLUSIONS

Variation in longevity is greater within US States than between them, yet cross-states disparities in mortality are increasing. This likely reflects the long-term consequences of rising social, economic, and political stratification for health inequalities both within and across states.

How Income Inequality and Race/Ethnicity Drive Obesity in U.S. Adults: 1999-2016

Obesity is a major public health problem both globally and within the U.S. It varies by multiple factors, including but not limited to income and sex. After controlling for potential covariates, there is little evidence to determine the association between income and obesity and how obesity may be moderated by sex and family income. We examined the association between income and obesity in U.S. adults aged 20 years and older, and tested whether this relationship differs by race or ethnicity groups. For this analysis, we used data from the 1999-2016 National Health and Nutrition Examination Surveys (NHANES). Obesity was determined using Body Mass Index ≥ 30 kg/m2; the Gini coefficient (GC) was calculated to measure income inequality using the Poverty Income Ratio (PIR). We categorized the PIR into five quintiles to examine the relationship between income inequality and obesity. For the first set of analyses, we used a modified Poisson regression in a sample of 36,665 adults, with an almost equal number of men and women (women's ratio was 50.6%), including 17,303 white non-Hispanics (WNH), 7475 black non-Hispanics (BNHs), and 6281 Mexican Americans. The models included age, racial/ethnic groups, marital status, education, health behaviors (smoking and drinking status and physical activities), health insurance coverage, self-reported health, and household structure (live alone and size of household). Adjusting for potential confounders, our findings showed that the association between PIR and obesity was positive and significant more frequently among WNH and BNH in middle and top PIR quintiles than among lower-PIR quintiles; this association was not significant in Mexican Americans (MAs). Results of GC in obese women showed that in comparison with WNHs (GC: 0.34, S.E.: 0.002), BNHs (GC: 0.38, S.E.: 0.004) and MAs (GC: 0.41, S.E.: 0.006) experienced higher income inequality, and that BNH obese men experienced the highest income inequality (GC: 0.45, S.E.: 0.011). The association between PIR and obesity was significant among WNHs and BNHs men in the 3rd, 4th and 5th PIR quintiles. The same association was not found for women. In treating obesity, policymakers should consider not only race/ethnicity and sex, but also strategies to reduce inequality in income.

Spatiotemporal Analysis of Overall Health in the United States Between 2010 and 2018

Background

Although many previous studies have documented spatial heterogeneity in health outcomes across the United States at different geographic scales, spatiotemporal analyses to understand overall health are scant.

Methodology

We used the County Health Rankings (CHR) data to analyze the three types of health outcomes, viz., overall health, length of life, and quality of life for 2010-2018 in the contiguous United States employing hierarchal Bayesian methods. Composite scores were created to proxy these outcomes utilizing predefined weights of several variables as recommended by CHR. Our methods assumed a convolution of spatially structured and unstructured errors to model the overall spatial error. Spatial effects were modeled using conditional autoregressive distribution.

Results

The substantial disparity in these health outcomes was evident, with counties having poorer health outcomes mostly concentrated in the southeastern United States. Models that incorporated county-level demographic and socioeconomic characteristics partially explained the observed spatial heterogeneity in health outcomes. Interestingly, there was no time effect in any of the outcomes suggesting a perpetuation of health disparity over the years.

Conclusions

County-specific health policy interventions that take into account the contextual factors might be beneficial in improving population health and breaking the perpetuation of health disparity.

Variations in Emotional, Sexual, and Physical Intimate Partner Violence Among Women in Uganda: A Multilevel Analysis

Evidence shows that a significant proportion of ever-partnered women suffer some form of intimate partner violence (IPV) perpetuated by male partners. The prevalence of IPV in sub-Saharan African countries is considerably higher than global estimates. Although existing studies show the effect of women's and intimate male partner's characteristics on IPV, knowledge on how these factors increase or reduce women's risk to specific types of IPV is limited. Using the 2016 Ugandan Demographic and Health Survey (UDHS), we examine regional variations in women's and intimate male partner's characteristics and their effect on emotional, sexual, and physical violence perpetuated by men and experienced by women in Uganda. The result shows that women's educational status is a significant predictor of all forms of IPV, whereas other characteristics, such as employment and housing ownership, have differential effects on specific types of IPV. Less educated women were more likely to experience emotional, sexual, and physical violence. Alcohol abuse was a significant determinant of men perpetuating all types of IPV; other male characteristics had differential effects on specific types of IPV. Male partners who abuse alcohol "often" and "sometimes" were more likely to commit acts of emotional, sexual, and physical violence against their female intimate partners. The findings also show that ~5%, ~8%, and ~2% of the variance in emotional, sexual, and physical violence (respectively; in the final models) are attributable to regional differences. The findings suggest the need for interventions aimed at increasing women's access to higher education, working with men and boys to reduce the occurrence of alcohol abuse and address harmful constructions of masculinity, and promoting gender equality among men as well as women.

Income Inequality and Obesity among US Adults 1999-2016: Does Sex Matter?

Obesity is a major public health problem that varies by income and sex, yet there is little evidence to determine the association between income inequality and obesity. We examined the association between income and obesity in adults ages 20 years and older and tested whether this relationship differs by sex in the United States. We used the 1999-2016 National Health and Nutrition Examination Survey (NHANES). We defined obesity if the body mass index was ≥30 kg/m2, and calculated the Gini coefficient (GC) to measure income inequality by using the Poverty Income Ratio. We examined the association between income and obesity using a Modified Poisson regression in a sample of 36,665 adults. We adjusted the models according to age, racial/ethnic groups, marital status, education, health behaviors, health insurance, self-reported health, and household structure. The association between income and obesity was consistently more significant among middle-income quintile and higher-income quintile men than among lower-income quintile men. The same association was not found for women; women in the highest income quintile were less likely to suffer from obesity than among lower-income quintile women. Our results suggest that policymakers should consider strategies to reduce structural inequality and encourage access to healthy foods and community-supported agricultural programs as nutritional interventions in low-income population settings.

Multilevel and spatial analyses of childhood malnutrition in Uganda: examining individual and contextual factors

In this study, we examine the concepts of spatial dependence and spatial heterogeneity in the effect of macro-level and micro-level factors on stunting among children aged under five in Uganda. We conducted a cross-sectional analysis of 3624 Ugandan children aged under five, using data from the 2016 Ugandan Demographic and Health Survey. Multilevel mixed-effect analysis, spatial regression methods and multi-scale geographically weight regression (MGWR) analysis were employed to examine the association between our predictors and stunting as well as to analyse spatial dependence and variability in the association. Approximately 28% of children were stunted. In the multilevel analysis, the effect of drought, diurnal temperature and livestock per km² on stunting was modified by child, parent and household factors. Likewise, the contextual factors had a modifiable effect on the association between child’s sex, mother’s education and stunting. The results of the spatial regression models indicate a significant spatial error dependence in the residuals. The MGWR suggests rainfall and diurnal temperature had spatial varying associations with stunting. The spatial heterogeneity of rainfall and diurnal temperature as predictors of stunting suggest some areas in Uganda might be more sensitive to variability in these climatic conditions in relation to stunting than others.

The effect of objective income and perceived economic resources on self-rated health

Background

Several studies have demonstrated that self-rated health status is affected by socioeconomic variables. However, there is little knowledge about whether perceived economic resources affect people’s health. The purpose of this study is to examine the relationship between self-rated health status and different measures of income. Specifically, the effect of both objective income and perceived economic resources are estimated for a very large sample of households in Italy. By estimating this relationship, this paper aims at filling the previously mentioned gap.

Methods

The data used are from the 2015 European Health Interview Survey and were collected using information from approximately 16,000 households in 562 Italian municipalities. Ordinary and generalized ordered probit models were used in estimating the effects of a set of covariates, among others measures of income, on the self-rated health status.

Results

The results suggest that the subjective income, measured by the perceived economic resources, affects the probability of reporting a higher self-rate health status more than objective income. The results also indicate that other variables, such as age, educational level, presence/absence of chronic disease, and employment status, affect self-rated health more significantly than objective income. It is also found that males report more frequently higher rating than females.

Conclusions

Our analysis demonstrates that perceived income affects significantly self-rated health. While self-perceived economic resources have been used to assess economic well-being and satisfaction, they can also be used to assess stress levels and related health outcomes. Our findings suggest that low subjective income adversely affects subjective health. Therefore, it is important to distinguish between effects of income and individuals’ perceptions of their economic resources or overall financial situation on their health. From a gender perspective, our results show that females are less likely to have high rating than males. However, as females perceive an improved economic situation, on the margin, the likelihood of a higher self-rated health increases compared to males.

Where and When: Sharpening the lens on geographic disparities in mortality

Life course theories suggest that geographic disparities in mortality may reflect a history of place-based exposures rather than (or in addition to) contemporaneous exposures; yet, few studies examined early life place exposures and later life mortality in the US due to data limitations. The aim of this study is to assess and compare the importance of state of birth and state of residence in predicting mortality for adults over age 50 in the US. Using nationally representative data of nearly 100,000 adults over age 50 from the National Longitudinal Mortality Study, we estimated individual mortality risk using multi-level logistic regression with state of birth and state of residence as second-level random effects. We assessed whether state of residence and state of birth contributed to the variation in adult mortality. We also decomposed state-of-residence random effects to compare “movers” and “stayers.” Our results indicate that state of birth is a stronger predictor of age-, race/ethnicity- and sex-adjusted mortality in the US than state of residence at the time of death. The adult mortality profiles of many states are substantially impacted by the composition of “movers.” Failing to account for residential mobility has clouded our understanding of the patterns and causes of geographic differences in adult mortality. Measures of geographic residence across the life course can improve models of adult mortality in the US and inform interventions to address geographic disparities in longevity.

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State of birth is a stronger predictor of later age mortality than state of residence.

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Geographic inequalities in mortality are results from complex groupings of “movers” and “stayers”.

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Incorporating geographic residence across the life course improves models of adult mortality.

Importance of lifestyle, stress, and chronic diseases in self-rated health of Korean doctors

The quality of medical services and the health of patients can be guaranteed when the doctors are healthy. In this study, we used the data from the 2016 Korean Physician Survey and analyzed the relationship of lifestyle, stress, and chronic diseases status with the self-rated health of Korean doctors. Among 7,631 doctors in Korea, 2,336 (30.6%) reported their self-rated health as ‘good’, 4,462 (58.5%) as ‘moderate’, and 833 (10.9%) as ‘bad’. The multinominal logistic regression analysis, showed that factors related to the self-rated health were age, type of healthcare facility, smoking, exercise, sleep duration, stress, and chronic diseases status. Since doctors’ lifestyle, stress, and chronic disease status were closely related to their self-rated health, it is imperative to prepare measures to protect doctors’ health in an intensive medical environment, where too many patients require treatment, due to the characteristics of the medical system in Korea.

Education and income-based inequality in tooth loss among Brazilian adults: does the place you live make a difference?

BACKGROUND

Socioeconomic inequalities in tooth loss might be minimized or potentialized by the characteristics of the context where people live. We examined whether there is contextual variation in socioeconomic inequalities in tooth loss across Brazilian municipalities.

METHODS

Data from the 2010 National Oral Health Survey of 9633 adults living in 157 Brazilian municipalities were used. The individual socioeconomic indicators were education and household income. At the municipal level, we used the Municipal Human Development Index (HDI) as our contextual indicator of socioeconomic status (low:< 0.699 versus high: > 0.70). The Relative (RII) and Slope (SII) Indexes of Inequality, Relative (RCI), and Absolute (ACI) Concentration Indexes were calculated to compare the magnitude of education and income-based inequalities among municipalities with low versus high HDI. Multilevel Poisson regression models with random intercepts and slopes were developed.

RESULTS

At the individual level, adults with lower education & income reported more tooth loss. The mean number of missing teeth was 9.52 (95% CI: 7.93-11.13) and 6.95 (95% CI: 6.43-7.49) in municipalities with low and high HDI, respectively. Municipalities with high HDI showed higher relative and absolute education-based inequality. For income-based inequalities, higher SII and RCI was observed in municipalities with lower HDI. A significant cross-level interaction indicated that high-education adults reported fewer missing teeth when they lived in municipalities with high HDI compared to adults with the same education level living in low HDI municipalities. For individuals with the lowest education level, there was no difference in the number of teeth between those from municipalities with high and low HDI.

CONCLUSIONS

There was a social gradient in tooth loss by education and income. Living in disadvantaged municipalities cannot overcome the risk associated with low schooling. The protective effect of higher education can be reduced when people live in disadvantaged areas.

Social capital and self-rated health of residents of Gauteng province: Does area-level deprivation influence the relationship?

Although social capital has been linked to population health, there is a dearth of studies on the phenomenon especially in sub-Saharan Africa. We investigated the individual and contextual effects of social capital indicators (group membership, registered to vote, perception towards safety in community and generalised trust) on the self-rated health (SRH) of the residents of Gauteng province. We used data from the 2015 Quality of Life (QoL) survey, which included a random representative sample of 27476 residents (level 1) in 508 administrative wards (level 2). We employed a multilevel logistic regression to examine the association of social capital and SRH (good vs poor). After adjusting for individual and area-level factors, no main effect of group membership (Adjusted OR: 0.93: 95% CI: 0.85-1.02), generalised trust (Adjusted OR: 1.01: 95% CI: 0.89-1.49) and registered to vote (Adjusted OR: 0.95; 95% CI: 0.82-1.10) was observed. However, if respondents were positive in their perception towards safety in community, there was a positive association with good SRH (Adjusted OR: 1.15; 95% CI: 1.01-1.31); while if residents reported a negative perception towards safety in community, a strong negative association with good SRH (Adjusted OR: 0.70; 95% CI: 0.62-0.79) was observed. Both ward variance and median odds ratio (MOR) indicate significant differences in good SRH by wards. A strong positive joint effect on the multiplicative scale was observed between satisfied with safety and the ward-level South African Multiple Deprivation Poverty Index (SAMPI), while a strong negative joint effect was also observed on a multiplicative scale between dissatisfied with safety and the SAMPI. Perception of safety in community is the core domain of social capital that significantly impacts the SRH of residents of Gauteng. Although the effect of perception towards safety in community on good SRH is influenced by ward deprivation,the effect is not dependent on the level of deprivation. Contextual factors as evidenced by the persistent MOR, in addition to individual factors, explain variation in reporting good SRH in the study area.

Cost-related unmet need for healthcare services in Kenya

Background

The assessment of unmet need is one way to gauge inequities in access to healthcare services. While there are multiple reasons for unmet need, financial barriers are a major reason particularly in low- and middle-income countries where healthcare systems do not offer financial protection. Moreover, accessibility and affordability are paramount in achieving universal health coverage. This study examines the extent of unmet need in Kenya due to financial barriers, the associated determinants, and the influence of regional variations.

Methods

We use data from the 2013 Kenya household health expenditure and utilization (KHHEUS) cross sectional survey. Self-reported unmet need due to lack of money and high costs of care is used to compute the outcome of interest. A multilevel regression model is employed to assess the determinants of cost-related unmet need, confounding for the effect of variations at the regional level.

Results

Cost-related barriers are the main cause of unmet need for outpatient and inpatient services, with wide variations across the counties. A positive association between county poverty rates and cost-related unmet is noted. Results reveal a higher intraclass correlation coefficient (ICC) of 0.359(35.9%) for inpatient services relative to 0.091(9.1%) for outpatient services. Overall, differences between counties accounted for 9.4% (ICC ~ 0.094) of the total variance in cost-related unmet need. Factors that positively influence cost-related unmet need include older household heads, inpatient services, and urban residence. Education of household head, good self-rated health, larger household size, insured households, and higher wealth quintiles are negatively associated with cost-related unmet need.

Conclusion

The findings underscore the important role of cost in enabling access to healthcare services. The county level is seen to have a significant influence on cost-related unmet need. The variations noted in cost-related unmet need across the counties signify the existence of wide disparities within and between counties. Scaling up of health financing mechanisms would fundamentally require a multi-layered approach with a focus on the relatively poor counties to address the variations in access. Further segmentation of the population for better targeting of health financing policies is paramount, to address equity in access for the most vulnerable and marginalized populations.

The relationship between gender roles and self-rated health: A perspective from an international study

OBJECTIVES

To examine the relationship between gender roles and self-rated health in older men and women from different contexts.

METHODS

2002 community-dwelling older adults from the International Mobility in Aging Study were recruited from 5 research sites. Gender role was measured with the 12-item Bem Sex Role Inventory, which categorized study participants into four gender roles: Masculine, Feminine, Androgynous, and Undifferentiated. Self-rated health was collapsed into a dichotomous variable (Very Good/Good and Fair/Poor/Very Poor). Prevalence risk ratios (PRR) of self-rated health relative to gender roles were estimated with Poisson regression models adjusted for all relevant confounders.

RESULTS

After complete adjustment, feminine (PRR 1.22 (95 % CI 1.01-1.49)) and undifferentiated (PRR 1.25 (95 % CI 1.05-1.50)) gender roles were associated with poorer relative self-rated health.

DISCUSSION

Gender roles confer independent risks and benefits for self-rated health in older adults.

A Health Profile and Overview of Healthcare Experiences of Cambodian American Refugees and Immigrants Residing in Southern California

Asian Americans are understudied in health research and often aggregated into one homogenous group, thereby disguising disparities across subgroups. Cambodian Americans, one of the largest refugee communities in the United States, may be at high risk for adverse health outcomes. This study compares the health status and healthcare experiences of Cambodian American refugees and immigrants. Data were collected via questionnaires and medical records from two community clinics in Southern California (n = 308). Chi square and t-tests examined the socio-demographic differences between immigrants and refugees, and ANCOVA models compared the mean differences in responses for each outcome, adjusting for age at immigration, education level, and clinic site. Cambodian American refugees reported overall lower levels of health-related quality of life (all p's < 0.05 in unadjusted models) and self-rated health [unadjusted means (SD) = 18.2 (16.8) vs. 21.7 (13.7), p < 0.05], but either similar or more positive healthcare experiences than Cambodian American immigrants. In adjusted analyses, refugees had higher rates of diabetes and cardiovascular disease risk (e.g. heart condition and hypertension; p's < 0.05) compared to Cambodian American immigrants. There were minimal differences in self-reported health behaviors between the two groups. There is a need for more health promotion efforts among Cambodian American refugees and immigrants to improve their health outcomes and perceived wellbeing.

The Role of Individual and Neighborhood Characteristics on Mental Health after a Period of Economic Crisis in the Lisbon Region (Portugal): A Multilevel Analysis

Mental health is an intrinsic dimension of health influenced by individual and contextual factors. This cross-sectional study analyzes the association between the individual, neighborhood characteristics, and one’s self-assessed mental health status in the Lisbon region after an economic crisis. Via the application of multilevel regression models, the study assesses the link between one’s neighborhood environment—deprivation, low self-assessed social capital, and low self-assessed satisfaction with the area of residence—and mental health regardless of one’s individual characteristics. Constraints related to the economic crisis play an important role in the explanation of poor mental health.

Differential associations between everyday versus institution-specific racial discrimination, self-reported health, and allostatic load among black women: implications for clinical assessment and epidemiologic studies

PURPOSE

Black women have the highest estimated allostatic load (AL). AL and self-perceived health are strong health predictors and have been linked to racial discrimination. Research suggests that everyday and institution-specific racial discrimination may predict different AL and self-reported health (SRH) outcomes. Furthermore, discrepancies between AL and self-perceived health could widen disparities. We estimated associations between everyday versus institution-specific racial discrimination with AL and SRH.

METHODS

Data are from a San Francisco Bay Area community sample of 208 black women aged 30-50 years. Participation involved a questionnaire, self-interview, blood draw, and anthropometric measurements. Adjusted generalized linear regression models estimated associations of racial discrimination with AL and SRH.

RESULTS

After adjusting for age, socioeconomic position, and medication use, institution-specific discrimination was negatively associated with AL (i.e., better health), whereas everyday experiences showed no association. Those reporting very-high (vs. moderate) institution-specific discrimination had lower AL (β = -1.31 [95% CI: -2.41, -0.20]; AL range: 0-15). No racial discrimination-SRH association was found.

CONCLUSIONS

For black women, (1) institution-specific racial discrimination may be differentially embodied compared with everyday experiences and (2) institutional racism may contribute to physiologic stress-regulation regardless of self-perceived health status. Potential factors that may contribute to an inverse racial discrimination-AL association, and future research, are discussed.

Social capital and perceived stress: The role of social context

BACKGROUND

The aim of this study is twofold: to investigate how much variance in individual perceived stress is attributed to household and area levels, respectively, and to examine the association between social capital at the individual, household, and area levels and perceived stress, while adjusting for various cofounders at the individual, household, and area levels.

METHODS

This study used data from the 2010 Seoul Welfare Panel Study conducted by the Seoul Welfare Foundation. A total sample of 5881 individuals in 2820 households within 25 areas was used for multilevel analysis.

RESULTS

The results showed that a relatively large proportion of variance in perceived stress was attributed to the household level (45.86%) in comparison with the area level (6.96%), which indicates that household or family context is more important in explaining variance in perceived stress than area. This study also found that some components of social capital were negatively associated with perceived stress, and the association between social capital and perceived stress varied depending on levels and types of social capital measures.

LIMITATIONS

This study is based on a cross-sectional design, and thus it is not clear about the temporal order between the relationship between social capital and perceived stress.

CONCLUSIONS

Overall, this study showed that research on social capital and mental health can be advanced by systematically investigating the role of household social capital, not just geographical social capital.

Aboriginal Status and Neighborhood Income Inequality Moderate the Relationship between School Absenteeism and Early Childhood Development

The negative impact of school absenteeism on children’s academic performance has been documented in the educational literature, yet few studies have used validated development indicators, or investigated individual and neighborhood characteristics to illuminate potential moderating factors. Using cross-sectional Early Development Instrument (EDI) panel data (2001–2005) we constructed multilevel linear and logistic regression models to examine the association between school absenteeism and early childhood development, moderated by Aboriginal status, length of school absence, neighborhood-level income inequality, and children’s sex assigned at birth. Our study included 3572 children aged four to eight in 56 residential neighborhoods in Saskatoon, Canada. Results indicated that Aboriginal children missing an average number of school days (3.63 days) had significantly lower EDI scores compared to non-Aboriginal children, controlling for individual and neighborhood factors. As school absenteeism lengthened, the gap in EDI scores between Aboriginal and non-Aboriginal children narrowed, becoming non-significant for absences greater than two weeks. Children with long-term school absence (>4 weeks of school), living in neighborhoods of low income inequality, had significantly better physical and social development scores compared to children from medium or high income inequality neighborhoods. Across all EDI domains, girls living in neighborhoods with low income inequality had significantly better EDI scores than boys in similar neighborhoods; however, sex-differences in EDI scores were not apparent for children residing in high income inequality neighborhoods. Results add to the literature by demonstrating differences in the relationship between school absenteeism and early developmental outcomes moderated by Aboriginal status, length of school absence, neighborhood income inequality, and sex assigned at birth. These moderating factors show that differential approaches are necessary when implementing policies and programs aimed at improving school attendance.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

Educational Disparities in Adult Health: U.S. States as Institutional Actors on the Association

Despite numerous studies on educational disparities in U.S. adult health, explanations for the disparities and their growth over time remain incomplete. We argue that this knowledge gap partly reflects an individualist paradigm in U.S. studies of educational disparities in health. These studies have largely focused on proximal explanations (e.g., individual behaviors) to the neglect of contextual explanations (e.g., economic policies). We draw on contextual theories of health disparities to illustrate how U.S. states, as institutional actors, shape the importance of education for health. Using two nationally-representative datasets and seven health measures for adults aged 45-89, we show that the size of the educational gradient in health varies markedly across states. The size varies because of variation in the health of lower-educated adults. We use state excise taxes on cigarettes to illustrate one way that states shape educational disparities in health. Our findings underscore the necessity of contextualizing these disparities.

Social Capital, Community Capacity, and Health

The capacity to practice health behavior is different for each individual. Community capacity and social capital deal with understanding the relationship between community members and with the factors that promote or delay collective activities. This study examines existing literature in relation to social capital, health, and community capacity. Bonding social capital shows the average value of the extent to which individuals trust each other and participate in groups, whereas bridging social capital shows the average value of the extent to which individuals participate in different formal groups. Community capacity seeks mutual cooperation based on trust, and cohesion minimizes community problems, and it has become evident that such capacity is a useful tool for health improvement.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol

INTRODUCTION

Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration.

METHODS AND ANALYSIS

This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions.

ETHICS AND DISSEMINATION

This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.

The relation between social capital and burnout: a longitudinal study

OBJECTIVES

Although social capital approach has showed its merits in predicting well-being and health in the working environment, studies examining the relation between social capital and burnout are scarce and limited to cross-sectional studies in the health care sector. This study aims to explore the longitudinal relationship between workplace social capital and burnout in a Belgian company in the energy sector. An additional aim was to assess whether the relation between workplace social capital and the dimensions of burnout was independent of job characteristics, i.e., the level of decision-making autonomy and task variety, and demographical variables.

METHODS

Analyses are conducted on the questionnaire data of 473 workers who participated at the two waves (2013 and 2014) of a longitudinal study.

RESULTS

The results showed a negative relation between social capital and distance and a positive relation between social capital and competence, after 1-year follow-up and after adjustments for baseline levels of the respective burnout dimension. In contrast with the literature, no relation between social capital and emotional exhaustion was found after adjustment for baseline level of emotional exhaustion. After additional adjustments were made for the job characteristics 'decision-making autonomy' and 'task variety', the relation between social capital and competence disappeared.

CONCLUSIONS

This study delivered evidence for the lagged relation between social capital and distance, even after controlling for demographical and job characteristics. Therefore, the findings suggest that organizations should pay attention to strategies enhancing social interaction, enabling to increase the levels of support, reciprocity, sharing and trust, in the prevention of burnout.

Non-completion of secondary education and early disability in Norway: geographic patterns, individual and community risks

Background

School non-completion and early work disability is a great public health challenge in Norway, as in most western countries. This study aims to investigate how medically based disability pension (DP) among young adults varies geographically and how municipal socioeconomic conditions interact with non-completion of secondary education in determining DP risk.

Methods

The study includes a nationally representative sample of 30% of all Norwegians (N = 350,699) aged 21–40 in 2010 from Statistic Norway’s population registries. Multilevel models incorporating factors at the individual, neighbourhood and municipal levels were applied to estimate the neighbourhood and municipality general contextual effects in DP receipt, and detect possible differences in the impact of municipal socioeconomic conditions on DP risk between completers and non-completers of secondary education.

Results

A pattern of spatial clustering at the neighbourhood (ICC = 0.124) and municipality (ICC = 0.021) levels are clearly evident, indicating that the underlying causes of DP receipt have a systematic neighbourhood and municipality variation in Norway. Non-completion of secondary education is strongly correlated with DP receipt among those younger than 40. Socioeconomic characteristics of the municipality are also significantly correlated with DP risk, but these associations are conditioned by the completion of secondary education. Living in a socioeconomically advantageous municipality (i.e. high income, high education levels and low unemployment and social security payment rates) is associated with a higher risk of DP, but only among those who do not complete their secondary education. Although the proportion of DPs was equal in rural and urban areas, it is evident that young people living in urban settings are more at risk of early DP than their counterparts living in rural parts of the country when controlling for other risk factors.

Conclusion

The association between school non-completion and DP risk varies between municipalities and local socioeconomic environments. The interplay between personal characteristics and the local community is important in DP risk among young adults, implying that preventive measures should be directed not only at the individual level, but also include the educational system and the local community.

Social epidemiology for the 21st century

Social epidemiology, as defined by the textbook of the same name (Berkman et al., 2014) is "that branch of epidemiology concerned with the way that social structures, institutions, and relationships influence health" (p. 2). As our Special Issue commemorates the 50th anniversary of Social Science & Medicine, it is worth noting that the Social Epidemiology office within the journal has existed only for a fraction of that time (fifteen years). So what has been learned in the fifteen years since the establishment of the new office? In this commentary, we spotlight some of the achievements, substantive topics, and future trends in the research papers that we have featured in our Section of the journal.

Community Social Capital, Built Environment, and Income-Based Inequality in Depressive Symptoms Among Older People in Japan: An Ecological Study From the JAGES Project

Background

Although reducing socioeconomic inequalities in depression is necessary, their associated factors have rarely been studied. This study aimed to screen the potential contextual factors associated with income-based inequality in older adults’ depression.

Methods

Using data from the Japan Gerontological Evaluation Study (JAGES) of 2013, we conducted an ecological study covering 77 communities in Japan. Our measures of socioeconomic inequalities in depression were the slope index of inequalities (SII) and the relative index of inequalities (RII) of the prevalence of depressive symptoms across three income levels. We categorized available community-level factors, including socio-demographic factors, social participation, social relationships, subjective changes in the residential area, and the built environment. These indicators were aggregated from individual responses of 51,962 and 52,958 physically independent men and women, respectively, aged 65 years or more. We performed multiple linear regression analyses to explore factors with statistical significance of a two-tailed P-value less than 0.05.

Results

Factors associated with shallower gradients in depression for men included higher participation in local activities and reception or provision of social support, which did not show significant association among women. Perceived increases in unemployment and economic inequalities were positively associated with larger inequalities in both genders (P < 0.05). The built environment did not indicate any significant association.

Conclusions

A community environment fostering social activities and relationships might be associated with smaller income-based inequalities in depression. There is a need for more deterministic studies for planning of effective community interventions to address socioeconomic inequalities in depression.

Democracy and health: Evidence from within-country heterogeneity in the Congo

The literature documents a positive association between democracy and health, and studies supporting this claim have largely relied on cross-country panel analyses. In many developing countries, however, local traditional leaders at the micro-level play a key role in individuals' daily lives while the influence of the national government is largely negligible. In response, this study revisits the relationship between democracy and health using micro-level household data from 816 randomly selected villages in Eastern Congo. We find little or no evidence that health outcomes are better in villages that are governed by elected leaders compared to villages where leaders are not elected. Our data suggest that efforts to improve health outcomes in this setting may need to focus on issues such as gender discrimination and education.

Disparities in Disability by Educational Attainment Across US States

OBJECTIVES

To examine how disparities in adult disability by educational attainment vary across US states.

METHODS

We used the nationally representative data of more than 6 million adults aged 45 to 89 years in the 2010-2014 American Community Survey. We defined disability as difficulty with activities of daily living. We categorized education as low (less than high school), mid (high school or some college), or high (bachelor's or higher). We estimated age-standardized disability prevalence by educational attainment and state. We assessed whether the variation in disability across states occurs primarily among low-educated adults and whether it reflects the socioeconomic resources of low-educated adults and their surrounding contexts.

RESULTS

Disparities in disability by education vary markedly across states-from a 20 percentage point disparity in Massachusetts to a 12-point disparity in Wyoming. Disparities vary across states mainly because the prevalence of disability among low-educated adults varies across states. Personal and contextual socioeconomic resources of low-educated adults account for 29% of the variation.

CONCLUSIONS

Efforts to reduce disparities in disability by education should consider state and local strategies that reduce poverty among low-educated adults and their surrounding contexts.

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

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

Contextual generalized trust and immunization against the 2009 A(H1N1) pandemic in the American states: A multilevel approach

The aim of the study was to investigate the association between contextual generalized trust and individual-level 2009 A(H1N1) pandemic immunization acceptance. A second aim was to investigate whether knowledge about the A(H1N1) pandemic mediated the association between contextual generalized trust and A(H1N1) immunization acceptance. Data from the National 2009 H1N1 Flu Survey was used. To capture contextual generalized trust, data comes from an aggregation of surveys measuring generalized trust in the American states. To investigate the association between contextual generalized trust and immunization acceptance, while taking potential individual-level confounders into account, multilevel logistic regression was used. The investigation showed contextual generalized trust to be significantly associated with immunization acceptance. However, controlling for knowledge about the A(H1N1) pandemic did not substantially affect the association between contextual generalized trust and immunization acceptance. In conclusion, contextual state-level generalized trust was associated with A(H1N1) immunization, but knowledge about A(H1N1) was not mediating this association.

Explaining Inequalities in Women's Mortality between U.S. States

Inequalities in women's mortality between U.S. states are large and growing. It is unknown whether they reflect differences between states in their population characteristics, contextual characteristics, or both. This study systematically examines the large inequalities in women's mortality between U.S. states using a multilevel approach. It focuses on “fundamental” social determinants of mortality at the individual and state levels as potential explanations. We analyze data from the 2013 public-use National Longitudinal Mortality Study on women aged 45–89 years and estimate multilevel logistic regression models. The models include women's personal characteristics (age, race/ethnicity, education, employment, income, and marriage) and states’ contextual characteristics (economic environment, social cohesion, sociopolitical orientation, physical infrastructure, and tobacco environment). We found that variation in women's mortality across states was significant (p<0.001). Adjusting for women's personal characteristics explained 30% of the variation. Additionally adjusting for states’ contextual characteristics explained 62% of the variation; the most important characteristics were social cohesion and economic conditions. No significant mortality differences between any two states remained after accounting for individual and contextual characteristics. Supplementary analyses of men indicate that state contexts have stronger and more pernicious consequences for women than men. Taken together, the findings underscore the importance of ‘bringing context back in’ and taking a multilevel approach when investigating geographic inequalities in U.S. mortality.

•

Variation in adult women's mortality risk across U.S. states is significant.

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Differences in both women's and states’ characteristics account for the variation.

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Most important state characteristics are social cohesion and economic conditions.

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States may have stronger and more pernicious consequences for women than men.

Social capital and health in Kenya: A multilevel analysis

Despite the acknowledgment that social capital is an important predictor of good health and overall well being in wealthy countries, little empirical research has been conducted in developing countries, particularly in Africa, to examine this relationship. This study examines the association between cognitive (trust) and structural (membership in organization) social capital on health at both the individual and contextual levels. Health was measured using answers to a subjective question on physical health and anxiety/worry suffered by individuals within the last 30 days. This study utilized Afrobarometer data collected in Kenya in 2005 to examine this relationship using multilevel logistic statistical modeling. Upon controlling for socioeconomic and demographic factors, social capital was found to be significantly associated with anxiety/worry and physical health in Kenya. Membership in organizations was associated with increased odds (OR = 1.34, 95%CI: 1.02-1.76) of physical health problems, while individual trust was associated with a 6% (OR = 0.94, 95%CI: 0.90-0.99) reduction in the likelihood of physical health problems. Conversely, generalized trust was associated with a 37% reduction in the odds (OR = 0.63, 95%CI: 0.40-0.99) of anxiety/worry, while individual trust was associated with a 5% reduction (OR = 0.95, 95%CI: 0.90-1.00) of anxiety/worry. With the exception of membership in an organization that exacerbates physical health, both individual level trust and generalized trust were associated with better health outcomes in Kenya. The availability of social organizations at the contextual level was associated with worsening anxiety/worry although the effect size was small. These results show that social capital, particularly trust, is a concept that can apply to different social and cultural contexts and can potentially be harnessed to improve health in settings that suffer from resource poverty.

Race, Ethnicity, and Self-Rated Health Status in the Behavioral Risk Factor Surveillance System Survey

This study examines the association between race and self-rated health status among Hispanic and non-Hispanic adults in the 2003 Behavioral Risk Factor Surveillance System survey ( N = 241,038). Logistic regression was used to estimate the odds of self-rated health as fair/poor for Hispanic Blacks, Hispanic Whites, and non-Hispanic Blacks as compared with non-Hispanic Whites. This study found that, first, Hispanic Blacks were more likely to rate their health as fair/poor than Hispanic and non-Hispanic Whites, and second, there was no difference between Hispanic and non-Hispanic Blacks. Specifically, when compared with non-Hispanic Whites, Hispanic Blacks and Whites were more likely to report their health as fair/poor. However, this association was stronger for Hispanic Blacks. More careful examination of race among Hispanics is imperative to unmask important health variations.

Education and Self-Reported Health: Evidence from 23 Countries on the Role of Years of Schooling, Cognitive Skills and Social Capital

We examine the contribution of human capital to health in 23 countries worldwide using the OECD Survey of Adult Skills, a unique large-scale international assessment of 16–65 year olds that contains information about self-reported health, schooling, cognitive skills and indicators of interpersonal trust, which represents the cognitive dimension of social capital. We identify cross-national differences in education, skill and social capital gradients in self-reported health and explore the interaction between human capital and social capital to examine if and where social capital is a mediator or a moderator of years of schooling and cognitive abilities. We find large education gaps in self-reported health across all countries in our sample and a strong positive relationship between self-reported health and both literacy and trust in the majority of countries. Education and skill gradients in self-reported health appear to be largest in the United States and smallest in Italy, France, Sweden and Finland. On average around 5.5% of both the schooling gap in self-reported health and the literacy gap in self-reported health can be explained by the higher levels of interpersonal trust that better educated/more skilled individuals have, although the mediating role of trust varies considerably across countries. We find no evidence of a moderation effect: the relationships between health and years of schooling and health and cognitive skills are similar among individuals with different levels of trust.

Depression, Sex and Gender Roles in Older Adult Populations: The International Mobility in Aging Study (IMIAS)

Objectives

To assess the associations between gender roles and depression in older men and women and whether gender roles are independent risk factors for depression.

Methods

International cross-sectional study of adults between 65 and 74 years old (n = 1,967). Depression was defined by a score of 16 or over in the Center for Epidemiologic Studies Depression Scale (CES-D). A validated 12-item Bem Sex Role Inventory (BSRI) was used to classify participants in gender roles (Masculine, Feminine, Androgynous, and Undifferentiated) using research site medians of femininity and masculinity as cut-off points. Poisson regressions were fitted to estimate the prevalence ratios (PR) of depression for each gender role compared to the masculine role, adjusting for sex, sufficiency of income, education, marital status, self-rated health, and chronic conditions.

Results

Among men, 31.2% were androgynous, 26% were masculine, 14.4% were feminine, and 28.4% were undifferentiated; among women, the corresponding percentages were 32.7%, 14.9%, 27%, and 25.4%. Both in men and in women, depressive symptoms (CES-D≥16) were more prevalent in those endorsing the undifferentiated type, compared to masculine, feminine or androgynous groups. However, after adjusting for potential confounders, compared to the masculine group only those endorsing the androgynous role were 28% less likely to suffer from depression: PR of 0.72 (95% CI: 0.55–0.93). In fully adjusted models, prevalence rates of depression were not different from masculine participants in the two other gender groups of feminine and undifferentiated.

Conclusions

Androgynous roles were associated with lower rates of depression in older adults, independently of being a man or a woman.