The impact of social assistance programs on population health: a systematic review of research in high-income countries

No change in substance use disorders or overdose after implementation of state Earned Income Tax Credit (EITC)

BACKGROUND

Inadequate income is associated with higher likelihood of experiencing a substance use disorder (SUD). This study tests whether the earned income tax credit (EITC), which issues supplemental income for workers with children in the U.S., is associated with lower rates of SUD and fatal overdose.

METHODS

We examined the effects of state-level refundable EITC presence and generosity (i.e., state EITC rate as a % of federal rate) on SUD-related outcomes (SUD prevalence and intentional and unintentional fatal overdose) using a difference-in-difference methodology, with both two-way fixed-effects models and event study plots. Several sensitivity analyses were conducted to assess the robustness of findings. Five data sources were used to create a combined state-level longitudinal dataset.

RESULTS

We did not find significant effects of refundable EITC presence or generosity on unintentional or intentional fatal overdose or SUD prevalence in two-way models. Event study models detected a very slight upward shift in SUD prevalence following refundable EITC implementation (not seen in sensitivity analyses) and no significant effects of EITC implementation on any of the fatal overdose outcomes.

CONCLUSIONS

Evidence regarding income support programs is being highly sought by policy makers as income support programs have become increasingly popular policy levers since the start of the COVID-19 pandemic. Our study indicates EITC policies likely have no impact on SUD or overdose, however, other income support programs without family restrictions are important to investigate further.

An ecological study of the correlation between COVID-19 support payments and overdose events in British Columbia, Canada

BACKGROUND

Pandemic income support payments have been speculatively linked to an increased incidence of illicit drug poisoning (overdose). However, existing research is limited.

METHODS

Collating Canadian Emergency Response Benefit (CERB) payment data with data on paramedic attended overdose and illicit drug toxicity deaths for the province of British Columbia at the Local Health Area (LHA) level, we conducted a correlation analysis to compare overdose rates before, during and after active CERB disbursement.

RESULTS

There were 20,014,270 CERB-entitled weeks identified among residents of British Columbia for the duration of the pandemic response program. Approximately 52 % of all CERB entitled weeks in the study were among females and approximately 48 % were among males. Paramedic-attended overdoses increased uniformly across the pre-CERB, CERB and post-CERB periods, while illicit drug toxicity deaths sharply increased and then remained high over the period of the study. Correlation analyses between overdose and CERB-entitled weeks approached zero for both paramedic-attended overdoses and illicit drug toxicity deaths.

CONCLUSIONS

These findings suggest that attributing the pandemic increase in overdose to income support payments is unfounded. Sustained levels of unacceptably high non-fatal and fatal drug poisonings that further increased at the start of the pandemic are reflective of complex pre-existing and pandemic-driven changes to overdose risk.

A Semantic Approach to Describe Social and Economic Characteristics That Impact Health Outcomes (Social Determinants of Health): Ontology Development Study

BACKGROUND

Social determinants of health (SDoH) have been described by the World Health Organization as the conditions in which individuals are born, live, work, and age. These conditions can be grouped into 3 interrelated levels known as macrolevel (societal), mesolevel (community), and microlevel (individual) determinants. The scope of SDoH expands beyond the biomedical level, and there remains a need to connect other areas such as economics, public policy, and social factors.

OBJECTIVE

Providing a computable artifact that can link health data to concepts involving the different levels of determinants may improve our understanding of the impact SDoH have on human populations. Modeling SDoH may help to reduce existing gaps in the literature through explicit links between the determinants and biological factors. This in turn can allow researchers and clinicians to make better sense of data and discover new knowledge through the use of semantic links.

METHODS

An experimental ontology was developed to represent knowledge of the social and economic characteristics of SDoH. Information from 27 literature sources was analyzed to gather concepts and encoded using Web Ontology Language, version 2 (OWL2) and Protégé. Four evaluators independently reviewed the ontology axioms using natural language translation. The analyses from the evaluations and selected terminologies from the Basic Formal Ontology were used to create a revised ontology with a broad spectrum of knowledge concepts ranging from the macrolevel to the microlevel determinants.

RESULTS

The literature search identified several topics of discussion for each determinant level. Publications for the macrolevel determinants centered around health policy, income inequality, welfare, and the environment. Articles relating to the mesolevel determinants discussed work, work conditions, psychosocial factors, socioeconomic position, outcomes, food, poverty, housing, and crime. Finally, sources found for the microlevel determinants examined gender, ethnicity, race, and behavior. Concepts were gathered from the literature and used to produce an ontology consisting of 383 classes, 109 object properties, and 748 logical axioms. A reasoning test revealed no inconsistent axioms.

CONCLUSIONS

This ontology models heterogeneous social and economic concepts to represent aspects of SDoH. The scope of SDoH is expansive, and although the ontology is broad, it is still in its early stages. To our current understanding, this ontology represents the first attempt to concentrate on knowledge concepts that are currently not covered by existing ontologies. Future direction will include further expanding the ontology to link with other biomedical ontologies, including alignment for granular semantics.

Prevalence of dental visits in older Japanese adults receiving public assistance

OBJECTIVES

Exemption from paying dental care costs among recipients of public assistance contributes to universal health care coverage. Although this system might reduce the financial barriers to dental care among patients, there are still several other barriers for public assistance recipients. Therefore, this study examined whether receiving public assistance was associated with a higher prevalence of dental visits for any reason, treatment and prevention.

METHODS

Data were obtained from 16 366 respondents from the 2019 wave of a nationwide cohort study on older adults in Japan. Poisson regression analyses with robust error variance were used to examine the associations between receiving public assistance and dental visits, adjusting for number of teeth, dental pain, periodontal conditions, age, sex, number of family members, education, equivalent household income, working status, instrumental activities of daily living, medical conditions, depressive symptoms, instrumental support and geographical variations.

RESULTS

More than half of the non-recipients of public assistance visited a dentist for some reason in the past 6 months. Meanwhile, only 37% of the recipients visited a dentist. In addition, almost half of the non-recipients had treatment visits, while only 34% of the recipients visited. Furthermore, 46% of the non-recipients had dental visits for prevention, while 32% of the recipients had preventive visits. In the fully adjusted models, compared to non-recipients, public assistance recipients were 24% (Prevalence Ratio [PR]: 0.76, 95% Confidence Intervals [CI]: 0.64, 0.90), 23% (PR: 0.77, 95% CI: 0.65, 0.92) and 21% (PR: 0.79, 95% CI: 0.65, 0.95) less likely to have dental visits for any reason, treatment, and prevention, respectively.

CONCLUSIONS

Although recipients were exempted from dental treatment fees, receiving public assistance was associated with a lower prevalence of dental visits for any reason, treatment and prevention. Future studies should identify the barriers to accessing dental care among public assistance recipients to improve dental visits.

Effect of modified income assistance payment schedules on substance use service access: Evidence from an experimental study

BACKGROUND

Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization.

METHODS

This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services.

RESULTS

Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants.

CONCLUSION

Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access.

Polypharmacy prevalence and associated factors in patients with systemic lupus erythematosus: A single-centre, cross-sectional study

OBJECTIVES

This study aimed to clarify factors associated with polypharmacy among patients with systemic lupus erythematosus.

METHODS

This single-centre cross-sectional study was conducted by reviewing the medical records and questionnaire data of 261 systemic lupus erythematosus patients at a teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as the regular administration of five or more oral medications; excessive polypharmacy consisted of the regular use of 10 or more oral medications. This study investigated (1) the prevalence of polypharmacy and excessive polypharmacy, (2) the distribution of medication types, and (3) the factors associated with polypharmacy and excessive polypharmacy.

RESULTS

The proportions of patients who exhibited polypharmacy and excessive polypharmacy were 70% and 19%, respectively. Polypharmacy was associated with older age, long duration of systemic lupus erythematosus, high disease activity, and administration of glucocorticoids or immunosuppressive agents. Excessive polypharmacy was associated with a higher updated Charlson comorbidity index, history of visits to multiple internal medicine clinics, and presence of public assistance.

CONCLUSIONS

Polypharmacy and excessive polypharmacy in patients with systemic lupus erythematosus are related to medical aspects such as disease severity and comorbidities in addition to social aspects such as hospital visitation patterns and economic status.

The MEDITAGING study: protocol of a two-armed randomized controlled study to compare the effects of the mindfulness-based stress reduction program against a health promotion program in older migrants in Luxembourg

BACKGROUND

Migration is a phenomenon worldwide, with older migrants, particularly those with fewer socioeconomic resources, having an increased risk of developing adverse cognitive and health outcomes and social isolation. Therefore, it is of utmost importance to validate interventions that promote healthy aging in this population. Previous studies have shown a positive impact of mindfulness based-stress reduction (MBSR) on outcomes such as cognition and sleep. However, only a few studies verified its potential in older adults, especially with vulnerable populations such as migrants. This article presents the protocol of the MEDITAGING study, which is the first to investigate the MBSR effects in migrants aged ≥55 in comparison to a health promotion program.

METHODS

MEDITAGING is a two-arm randomized, double-blinded, controlled study, which will include older Portuguese-speaking migrants (n = 90). Participants are randomized to the MBSR or a health promotion program. Both interventions are conducted in groups over a total of 8 weeks, incorporating weekly meetings, an additional 4-hour class, and extra at-home tasks. The health promotion program has the same structure as the MBSR but comprises different activities related to dementia prevention, healthy habits, cognitive stimulation, sleeping, nutrition, watercolor painting, and physical activity. The assessment of executive functioning, physiological stress measures, self-reported questionnaires, and qualitative interviews are conducted at baseline, after 8 weeks (post-intervention), and at a follow-up session (from one to 3 months thereafter). Analyzes will be conducted using a modified intention-to-treat approach (all participants with at least 3 days of participation in the group-sessions and one post-intervention observation).

DISCUSSION

This study will test effects of a mindfulness-based intervention against an active control condition in older adult migrants, which few studies have addressed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05615337 (date of registration: 27 September 2022; date of record verification: 14 November 2022).

Experiences and needs of welfare benefit recipients regarding their welfare-to-work services and case workers

BACKGROUND

This study aimed to explore the experiences and needs of (ex-)welfare benefit recipients from a large urban municipality in the Netherlands regarding their welfare-to-work services and their case workers.

METHODS

Quantitative data from a client satisfaction survey that was filled out by 213 people (response rate 11%) who received welfare-to-work services was combined with results from four group interviews with a total of 15 people receiving welfare-to-work services. Verbatim transcripts from the interviews were analysed using inductive thematic analysis.

RESULTS

The survey results showed that most clients were reasonably satisfied with the welfare-to-work services they received. Four main themes emerged from the interviews: (1) experiences and needs related to the interactions between case workers and benefit recipients; (2) the need for tailored services; (3) the complicating role of the system the case workers operate within; and (4) the existence of differences between case workers regarding how strict they followed the rules and to what extent they connected with their clients on a personal level.

CONCLUSIONS

Our findings show that clients were reasonably satisfied with the welfare-to-work services provided by their municipality but that there is still room for improvement. Case workers should have good social skills to build a trusting relationship with the client, welfare-to-work services should be tailored to the individual, and clear concise information should be given to welfare benefit recipients, especially with regard to what benefit recipients can expect of the municipality and the case workers, given their dual role in supporting (re-)integration to work and monitoring benefit eligibility.

Identifying meaningful subpopulation segments among older public assistance recipients: a mixed methods study to develop tailor-made health and welfare interventions

BACKGROUND

Public assistance recipients have diverse and complex needs for health and social support in addition to financial support. Segmentation, which means dividing the population into subgroups (segments) with similar sociodemographic characteristics, is a useful approach for allocating support resources to the targeted segments. Clustering is a commonly used statistical method of segmentation in a data-driven marketing approach. This explanatory sequential mixed methods study applied a clustering technique, aiming to identify segments among older public assistance recipients quantitatively, and assess the meaningfulness of the identified segments in consultation and support activities for older recipients qualitatively.

METHODS

We identified the segments of older recipients in two municipalities using probabilistic latent semantic analysis, a machine learning-based soft clustering method. Semi-structured interviews were subsequently conducted with caseworkers to ask whether the identified segments could be meaningful for them in practice and to provide a reason if they could not think of any older recipients from the segment.

RESULTS

A total of 3,165 older people on public assistance were included in the analysis. Five distinct segments of older recipients were identified for each sex from 1,483 men and 1,682 women. The qualitative findings suggested most of identified segments reflected older recipients in practice, especially two of them: female Cluster 1 (facility residents aged over 85 years with disability/psychiatric disorder), and female Cluster 2 (workers). Some caseworkers, however, did not recall older recipients in practice when working with certain segments.

CONCLUSIONS

A clustering technique can be useful to identify the meaningful segments among older recipients and can potentially discover previously unrecognized segments that may not emerge through regular consultation practices followed by caseworkers. Future research should investigate whether tailored support interventions for these identified segments are effective.

Reconsidering economic interventions to reduce oral health inequalities

Despite the general recognition of economic factors as fundamental upstream social determinants of health inequalities, interventions to improve health and reduce inequalities tend to focus on proximal health determinants. However, recent socioeconomic crises have increased the focus on economic factors. Health-related approaches to address economic factors can be divided into two categories: (1) indirect approaches, such as financial support for obtaining dental care and fiscal policies targeting unhealthy commodities and (2) direct approaches, such as cash transfers or provision of a universal basic income. For indirect approaches, policies reducing out-of-pocket payments for dental care appear to improve access to services and reduce oral health inequalities. Price policies targeting tobacco and sugar through taxation are associated with declines in periodontal disease and caries, and sugar taxation appears to reduce oral health inequalities. As regards direct approaches, studies on cash transfers to low-income individuals have found no positive impact on dental visits, while results in relation to caries prevention were inconclusive. No dental studies examined the effect of a population approach to income security, such as basic income. Research on economic interventions for oral health inequalities is scarce, and studies using causal inference methods and natural experiments are urgently needed.

The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis

BACKGROUND

With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions.

OBJECTIVE

This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity.

METHODS

This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level.

RESULTS

The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis.

CONCLUSIONS

The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health.

Designing a generic, adaptive protocol resource for the measurement of health impact in cash transfer pilot and feasibility studies and trials in high-income countries

INTRODUCTION

In the context of the COVID-19 pandemic, upstream interventions that tackle social determinants of health inequalities have never been more important. Evaluations of upstream cash transfer trials have failed to capture comprehensively the impacts that such systems might have on population health through inadequate design of the interventions themselves and failure to implement consistent, thorough research measures that can be used in microsimulations to model long-term impact. In this article, we describe the process of developing a generic, adaptive protocol resource to address this issue and the challenges involved in that process. The resource is designed for use in high-income countries (HIC) but draws on examples from a UK context to illustrate means of development and deployment. The resource is capable of further adaptation for use in low- and middle-income countries (LMIC). It has particular application for trials of Universal Basic Income but can be adapted to those covering other kinds of cash transfer and welfare system changes.

METHODS

We outline two types of prospective intervention based on pilots and trials currently under discussion. In developing the remainder of the resource, we establish six key principles, implement a modular approach based on types of measure and their prospective resource intensity, and source (validated where possible) measures and baseline data primarily from routine collection and large, longitudinal cohort studies. Through these measures, we seek to cover all areas of health impact identified in our theoretical model for use in pilot and feasibility studies.

RESULTS

We find that, in general, self-reported measures alongside routinely collected linked respondent data may provide a feasible means of producing data capable of demonstrating comprehensive health impact. However, we also suggest that, where possible, physiological measures should be included to elucidate underlying biological effects that may not be accurately captured through self-reporting alone and can enable modelling of long-term health outcomes. In addition, accurate self-reported objective income data remains a challenge and requires further development and testing. A process of development and implementation of the resource in pilot and feasibility studies will support assessment of whether or not our proposed health outcome measures are acceptable, feasible and can be used with validity and reliability in the target population.

DISCUSSION

We suggest that while Open Access evaluation instruments are available and usable to measure most constructs of interest, there remain some areas for which further development is necessary. This includes self-reported wellbeing measures that require paid licences but are used in a range of nationally important longitudinal studies instead of Open Access alternatives.

Childhood Abuse, Intimate Partner Violence in Young Adulthood, and Welfare Receipt by Midlife

OBJECTIVE

To investigate prospective associations between type of child abuse (physical, sexual, both), timing (childhood, young adulthood, both), and welfare receipt into middle-age.

METHODS

Database linkage study using the Quebec Longitudinal Study of Kindergarten Children cohort born in 1980 and government administrative databases (N = 3020). We assessed parental tax returns, family and personal background characteristics (1982-1987). At age 22 years, participants answered retrospective questionnaires on experienced childhood abuse (physical, sexual abuse < age 18 years) and intimate partner violence (IPV) (ages 18-22). Main outcome was years on social assistance, on the basis of participant tax returns (ages 23-37 years). Analysis included weights for population representativeness.

RESULTS

Of 1690 participants (54.4% females) with available data, 22.4% reported childhood abuse only, 14.5% IPV only, and 18.5% both. Prevalence of childhood physical, sexual, and both was 20.4%, 12.2%, and 8.3%, respectively. Adjusting for socioeconomic background and individual characteristics, we found that childhood physical abuse alone and physical or sexual abuse combined were associated with a two-fold risk of welfare receipt, as compared to never-abused (adjusted incidence risk ratio 2.43, 95% confidence interval [CI], 1.65-3.58; and adjusted incidence risk ratio 2.04, 95% CI, 1.29-3.23, respectively). Repeated abuse (childhood abuse combined with adult IPV) had a three-fold risk (adjusted incidence ratio 3.59, 95% CI, 2.39-5.37).

CONCLUSIONS

Abuse across several developmental periods (childhood and young adulthood) is associated with increased risks of long-term welfare receipt, independently of socioeconomic background. Results indicate a dose-response association. Early prevention and targeted identification are crucial to preventing economic adversity that may potentially lead to intergenerational poverty.

Are Neighborhood Characteristics Associated With Outcomes After THA and TKA? Findings From a Large Healthcare System Database

BACKGROUND

Non-White patients have higher rates of discharge to an extended care facility, hospital readmission, and emergency department use after primary THA and TKA. The reasons for this are unknown. Place of residence, which can vary by race, has been linked to poorer healthcare outcomes for people with many health conditions. However, the potential relationship between place of residence and disparities in these joint arthroplasty outcomes is unclear.

QUESTIONS/PURPOSES

(1) Are neighborhood-level characteristics, including racial composition, marital proportions, residential vacancy, educational attainment, employment proportions, overall deprivation, access to medical care, and rurality associated with an increased risk of discharge to a facility, readmission, and emergency department use after elective THA and TKA? (2) Are the associations between neighborhood-level characteristics and discharge to a facility, readmission, and emergency department use the same among White and Black patients undergoing elective THA and TKA?

METHODS

Between 2007 and 2018, 34,008 records of elective primary THA or TKA for osteoarthritis, rheumatoid arthritis, or avascular necrosis in a regional healthcare system were identified. After exclusions for unicompartmental arthroplasty, bilateral surgery, concomitant procedures, inability to geocode a residential address, duplicate records, and deaths, 21,689 patients remained. Ninety-seven percent of patients in this cohort self-identified as either White or Black, so the remaining 659 patients were excluded due to small sample size. This left 21,030 total patients for analysis. Discharge destination, readmissions within 90 days of surgery, and emergency department visits within 90 days were identified. Each patient's street address was linked to neighborhood characteristics from the American Community Survey and Area Deprivation Index. A multilevel, multivariable logistic regression analysis was used to model each outcome of interest, controlling for clinical and individual sociodemographic factors and allowing for clustering at the neighborhood level. The models were then duplicated with the addition of neighborhood characteristics to determine the association between neighborhood-level factors and each outcome. The linear predictors from each of these models were used to determine the predicted risk of each outcome, with and without neighborhood characteristics, and divided into tenths. The change in predicted risk tenths based on the model containing neighborhood characteristics was compared to that without neighborhood characteristics.The change in predicted risk tenth for each outcome was stratified by race.

RESULTS

After controlling for age, sex, insurance type, surgery type, and comorbidities, we found that an increase of one SD of neighborhood unemployment (odds ratio 1.26 [95% confidence interval 1.17 to 1.36]; p < 0.001) was associated with an increased likelihood of discharge to a facility, whereas an increase of one SD in proportions of residents receiving public assistance (OR 0.92 [95% CI 0.86 to 0.98]; p = 0.008), living below the poverty level (OR 0.82 [95% CI 0.74 to 0.91]; p < 0.001), and being married (OR 0.80 [95% CI 0.71 to 0.89]; p < 0.001) was associated with a decreased likelihood of discharge to a facility. Residence in areas one SD above mean neighborhood unemployment (OR 1.12 [95% CI [1.04 to 1.21]; p = 0.002) was associated with increased rates of readmission. An increase of one SD in residents receiving food stamps (OR 0.83 [95% CI 0.75 to 093]; p = 0.001), being married (OR 0.89 [95% CI 0.80 to 0.99]; p = 0.03), and being older than 65 years (OR 0.93 [95% CI 0.88 to 0.98]; p = 0.01) was associated with a decreased likelihood of readmission. A one SD increase in the percentage of Black residents (OR 1.11 [95% CI 1.00 to 1.22]; p = 0.04) and unemployed residents (OR 1.15 [95% CI 1.05 to 1.26]; p = 0.003) was associated with a higher likelihood of emergency department use. Living in a medically underserved area (OR 0.82 [95% CI 0.68 to 0.97]; p = 0.02), a neighborhood one SD above the mean of individuals using food stamps (OR 0.81 [95% CI 0.70 to 0.93]; p = 0.004), and a neighborhood with an increasing percentage of individuals older than 65 years (OR 0.90 [95% CI 0.83 to 0.96]; p = 0.002) were associated with a lower likelihood of emergency department use. With the addition of neighborhood characteristics, the risk prediction tenths of the overall cohort remained the same in more than 50% of patients for all three outcomes of interest. When stratified by race, neighborhood characteristics increased the predicted risk for 55% of Black patients for readmission compared with 17% of White patients (p < 0.001). The predicted risk tenth increased for 60% of Black patients for emergency department use compared with 21% for White patients (p < 0.001).

CONCLUSION

These results can be used to identify high-risk patients who might benefit from preemptive interventions to avoid these particular outcomes and to create more realistic, comprehensive risk adjustment models for value-based care programs. Additionally, this study demonstrates that neighborhood characteristics are associated with greater risk for these outcomes among Black patients compared with White patients. Further studies should consider that race/ethnicity and neighborhood characteristics may not function independently from each other. Understanding this link between race and place of residence is essential for future racial disparities research.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Changes in health-related quality of life scores among low-income patients on social welfare programs in Japan during the COVID-19 pandemic: a single-center repeated cross-sectional study

BACKGROUND

Low-income is one of the well-established determinants of people's health and health-related behavior, including susceptibility to the coronavirus disease 2019 (COVID-19) infection. Two social welfare services are available in Japan to support financial and medical care among low-income patients: Public Assistance (PA), which provide both minimum income and medical costs; and Free/Low-Cost Medical Care (FLCMC), wherein only medical costs were covered. In this study, changes in Health-Related Quality of Life (HRQOL) scores of low-income patients on PA and FLCMC, before and after COVID-19 pandemic, were described and compared against those that are not utilizing the said services (comparison group) to evaluate the contribution of social welfare services in protecting the HRQOL of the beneficiaries during the pandemic.

METHODS

We used repeated cross-sectional data of adult beneficiaries of FLCMC and PA, as well as those without social welfare services, who regularly visit the Kamigyo clinic in Kyoto, Japan. We collected the data from 2018 and 2021 using a questionnaire on patients' socioeconomic attributes and the Japanese version of Medical Outcomes Study 12-Item Short Form Health Survey (SF-12). The Japanese version of SF-12 can calculate the three components scores: physical health component summary (PCS), the mental health component summary (MCS), and the role-social component summary (RCS), which can be transformed to a 0-100 range scale with a mean of 50 and standard deviation of 10.

RESULTS

Data of 200 and 174 beneficiaries in 2018 and 2021, respectively, were analyzed. Low-income patients on social welfare services had lower PCS, and RCS than the comparison group in both years. Multiple linear regression analyses with cluster-adjusted standard error estimator showed that the decline in MCS was significantly higher among FLCMC beneficiaries than in those without welfare services (Beta: -4.71, 95% Confidence Interval [CI]: -5.79 to -3.63, p < 0.01), and a decline in MCS among PA recipients was also observed (Beta: -4.27, 95% CI: -6.67 to -1.87 p = 0.02).

CONCLUSIONS

Low-income beneficiaries of social welfare may have experienced mental health deterioration during the COVID-19 pandemic. To maintain healthy lives during the pandemic, additional support on mental health for low-income recipients of social welfare services may be required.

Impact of a universal perinatal home-visiting program on reduction in race disparities in maternal and child health: Two randomised controlled trials and a field quasi-experiment

Background

Public health interventions must become accountable for reduction of race disparities, particularly among Black, Hispanic, and Non-Hispanic White families in the United States. Family Connects (FC) is a universal perinatal home-visiting program that assesses family-specific needs, offers support, and provides connections to community resources to address identified needs. Two previously-published randomised controlled trials and a field quasi-experiment have shown positive impact on maternal mental health, infant emergency medical care utilization, and government investigations for child maltreatment; however, these reports have not tested impact on reducing race disparities in these outcomes. The current report examined three questions in these trials: 1) the extent of race disparities in maternal and infant health and well-being, absent intervention; 2) whether intervention can be implemented with high reach and fidelity among all race groups; and 3) whether assignment to intervention reduces race disparities in important outcomes.

Methods

Data were re-examined from: 1) a randomised controlled trial of 4777 birthing families in Durham, NC, USA; 2) a replication randomised controlled trial of 923 birthing families in Durham, NC, USA; and 3) a quasi-experiment of 988 birthing families in rural NC, USA. Families were classified as Black, Hispanic, Non-Hispanic White, or Other. Disparity reduction was tested by the interaction effect between treatment assignment and race.

Findings

1) In the absence of intervention, large and statistically significant differences between Black familes and Non-Hispanic White families were found in maternal anxiety, maternal depression, father non-support, child emergency medical care, and child maltreatment investigations. Few differences were found between Non-Hispanic White familes and Hispanic families.2) High rates of participation in treatment were found for each race group.3) Across studies, assignment to FC was associated with statistically significant reductions in 7 of 12 disparities, in maternal anxiety and depression, father non-support, infant emergency medical care, and child maltreatment investigations.

Interpretation

This study provides a method, metric, and mandate to prioritise testing of whether public health interventions reduce race disparities in family outcomes.

Funding

This research was supported by grant R01HD069981 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and a grant from The Duke Endowment.

Effects of social assistance on self-rated health

Based on the China Health and Retirement Longitudinal Study (CHARLS) data in 2018, medical assistance and life assistance have significant negative influences on self-rated health, found via an empirical analysis based on the Oprobit model. Such negative influences are robust based on the substitution of explained variables and propensity score matching. It can be found from a heterogeneity analysis that the negative influences of medical assistance on self-rated health are more significant in urban residents and residents in Central China and East China. Meanwhile, negative influences of life assistance on self-rated health are more significant in urban residents, and residents in Central China, East China, and Northeast China. This study provides empirical evidence to improve the health of residents by using medical assistance and life assistance accurately and offers important policy enlightenments to formulate appropriate social assistance policies.

A Model for Evaluating the Effectiveness of Precise Governance of Social Assistance from a Management Perspective and Environment of Public Health

The research study describes the assessment model and its effect of precise governance of social assistance related to management's perspective. This research study was conducted in Chinese organizations which are related to the precise governance of social assistance. This research study is based on primary data analysis for gathering the data using specific questions related to social assistance and management. In this research study, the precise governance of social assistance is considered an independent variable, and management's perspective is the dependent variable. The planning, designing, leading, the growth of the organization process, and system control are all subparts of management's perspective. To measure the data, this study used 100 plus respondent persons who know social assistance related to governance and management. To measure the data, smart PLS software, and AMOS software and run informative results included growth curve model, the smart algorithm model, the regression weighted analysis, the correlation, covariance, minimization history, and assessment of normality. The overall result found that precise governance of social assistance shows positive and significant effects in the management perspectives.

Leisure Possibilities of Adults Experiencing Poverty: A Community-Based Participatory Study

Background. Poverty disproportionally affects persons with disabilities, elderly individuals and racialized groups. Leisure, play and rest are not prioritized in either services for or research with people living in poverty. Purpose. This study aims to examine the facilitators and barriers to participation in meaningful leisure activities for adults living in poverty. Method. We used community-based participatory research and art-based elicitation strategies with 39 service users at a food security organization. Findings. Individuals experiencing poverty value and engage in a variety of free and affordable leisure activities, but they are not afforded the necessary leisure opportunities, accommodations and supports as the general population. We co-created a map of local leisure resources to foster collective capacity in leisure planning, and to support organizations working with this population. Implications. Occupational therapists can work alongside members of underserved communities to uncover and address the systemic and local contextual barriers to engagement in leisure activities.

Public assistance program and depressive symptoms of the recipient: a cross-sectional Japan Gerontological Evaluation Study

Background

Mental health conditions among older recipients of public assistance should be considered because it has been reported that public assistance recipients tend to have higher risks of morbidity than non-recipients, and mental health is strongly related to frailty. We aimed to examine whether older recipients of public assistance were more likely to have depressive symptoms compared to non-recipients.

Methods

Data were obtained from the Japan Gerontological Evaluation Study, a 2016 community-based study of older adults. Poisson regression analyses with a robust error variance using fixed effects were conducted to examine the relationship between receiving public assistance and depressive symptoms controlling for sociodemographic factors. Depressive symptoms were assessed by the Geriatric Depression Scale 15.

Results

We found that the older recipients of public assistance were 1.57 times (95% confidence interval [CI]: 1.47, 1.67) more likely to have depressive symptoms compared to non-recipients. We also found that, when additionally adjusting for indicators of social participation, this relationship was slightly attenuated; however, the recipients still had worse mental health issues (Prevalence ratio: 1.33; 95% CI: 1.25, 1.42).

Conclusions

Even after controlling for sociodemographic factors, older recipients of public assistance tended to be more depressed than non-recipients. However, our findings also indicated that social participation could slightly attenuate the negative relationship between receiving public assistance and depressive symptoms. Therefore, the public assistance program needs to consider the inclusion of mental healthcare support in addition to financial support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02868-0.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study

AIMS/INTRODUCTION

Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data.

MATERIALS AND METHODS

We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome.

RESULTS

We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis.

CONCLUSIONS

Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

Effect of alternative income assistance schedules on drug use and drug-related harm: a randomised controlled trial

Background

The synchronised monthly disbursement of income assistance, whereby all recipients are paid on the same day, has been associated with increases in illicit drug use and serious associated harms. This phenomenon is often referred to as the cheque effect. Because payment variability can affect consumption patterns, this study aimed to assess whether these harms could be mitigated through a structural intervention that varied income assistance payment timing and frequency.

Methods

This randomised, parallel group trial was done in Vancouver, Canada, and enrolled recipients of income assistance whose drug use increased around payment days. The recipients were randomly assigned 1:2:2 to a control group that received monthly synchronised income assistance payments on government payment days, a staggered group in which participants received single desynchronised monthly income assistance payments, or a split and staggered group in which participants received desynchronised income assistance payments split into two instalments per month, 2 weeks apart, for six monthly payment cycles. Desynchronised payments in the intervention groups were made on individual payment days outside the week of the standard government schedules. Randomisation was through a pre-established stratified block procedure. Investigators and statisticians were masked to group allocation, but participants and front-line staff were not. Complete final results are reported after scheduled interim analyses and the resulting early stoppage of recruitment. Under intention-to-treat specifications, generalised linear mixed models were used to analyse the primary outcome, which was escalations in drug use, predefined as a 40% increase in at least one of: use frequency; use quantity; or number of substances used during the 3 days after government payments. Secondary analyses examined analogous drug use outcomes coinciding with individual payments as well as exposure to violence. This trial is registered with ClinicalTrials.gov, NCT02457949.

Findings

Between Oct 27, 2015, and Jan 2, 2019, 45 participants were enrolled to the control group, 72 to the staggered group, and 77 to the split and staggered group. Intention-to-treat analyses showed a significantly reduced likelihood of increased drug use coinciding with government payment days, relative to the control group, in the staggered (adjusted odds ratio 0·38, 95% CI 0·20–0·74; p=0·0044) and split and staggered (0·44, 0·23–0·83; p=0·012) groups. Findings were consistent in the secondary analyses of drug use coinciding with individual payment days (staggered group 0·50, 0·27–0·96, p=0·036; split and staggered group 0·49, 0·26–0·94, p=0·030). However, secondary outcome analyses of exposure to violence showed increased harm in the staggered group compared with the control group (2·71, 1·06–6·91, p=0·037). Additionally, 51 individuals had a severe or life-threatening adverse event and there were six deaths, none of which was directly attributed to study participation.

Interpretation

Complex results indicate the potential for modified income assistance payment schedules to mitigate escalations in drug use, provided measures to address unintended harms are also undertaken. Additional research is needed to clarify whether desynchronised schedules produce other unanticipated consequences and if additional measures could mitigate these harms.

Funding

Canadian Institutes of Health Research, Providence Health Care Research Institute, Peter Wall Institute for Advanced Research, Michael Smith Foundation for Health Research.

Health service use of Australian unemployment and disability benefit recipients: a national, cross-sectional study

Background

Healthcare is funded and delivered separately from income support programs such as unemployment and disability benefits. Greater understanding of the health service use (HSU) of benefit recipients would support more effective design and delivery of health and income support programs. This study aimed to characterise the HSU of disability and unemployment benefit recipients relative to people earning wages, while controlling for personal, household and health-related factors associated with HSU in benefit recipients.

Methods

A cross-sectional national survey of 9110 working age Australian adults in three groups: (1) 566 receiving the disability support pension (DSP); (2) 410 receiving unemployment benefits; and (3) 8134 earning wages. Outcomes included prevalence and frequency of health professional consultations, hospital attendance and admission in the past 12 months, as well as medication and supplement use in the past 2 weeks. Analyses compared DSP and unemployment benefit recipients to wage earners using prevalence ratios and incident rate ratios, adjusted for predisposing, enabling and need factors that may affect HSU.

Results

In adjusted regression models, both DSP and unemployment benefit recipients were significantly more likely than wage earners to have consulted psychologists and social workers. DSP recipients also reported a significantly higher prevalence of consultations with General Practitioners (GPs), specialist physicians and podiatrists.. Both groups reported significantly more frequent consultations with GPs and DSP recipients with specialists. No differences were observed between groups for hospital attendance or admission, or supplement use in fully adjusted models, though the DSP group reported more prevalent medication use than wage earners. Inclusion of confounders including self-assessed health, disability severity, health insurance status, and financial resources attenuated the relationship between benefit receipt and HSU, however significant associations were still observed.

Conclusions

People receiving unemployment and disability insurance benefits use significantly more health services than wage earners. A range of personal and clinical characteristics explained much, but not all, of the association between greater HSU and benefit receipt. Greater coordination between health and income support systems may improve health, reduce HSU and improve work ability in unemployed and working age people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06255-0.

Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs

BACKGROUND AND AIMS

Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm.

DESIGN

This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV.

MEASUREMENTS

The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome.

FINDINGS

Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P <  0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities.

CONCLUSIONS

In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.

Cash Transfers and Health

Financial resources are known to affect health outcomes. Many types of social policies and programs, including social assistance and social insurance, have been implemented around the world to increase financial resources. We refer to these as cash transfers. In this article, we discuss theory and evidence on whether, how, for whom, and to what extent purposeful cash transfers improve health. Evidence suggests that cash transfers produce positive health effects, but there are many complexities and variations in the outcomes. Continuing research and policy innovation-for example, universal basic income and universal Child Development Accounts-are likely to be productive.

Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review

BACKGROUND

Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries.

METHODS

We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

FINDINGS

Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01-1·26]) and high support needs (RR 1·42 [1·19-1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear.

INTERPRETATION

Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes.

FUNDING

Inner City Health Associates.

Psychological distress among low-income mothers: the role of public and private safety nets

Poverty is linked with a host of negative outcomes. Approximately one-third of unmarried mothers and their children live in poverty in the United States. Public and private supports have the potential to mitigate the adverse effects of poverty; however, these supports may be unstable over time. The purpose of this study was to determine public and private safety net configurations of low-income mothers longitudinally and test linkages between safety net configurations and maternal psychological distress. Using longitudinal data from the Welfare, Children, Families project conducted in 1999, 2001, and 2005 (n = 1,987), results of multilevel models of change indicated that less than one-half of low-income mothers used public assistance and had private support at any one point. Safety net configurations and psychological distress levels changed over time with deterioration occurring more than improvement, and private safety net availability offered protection from psychological distress. These findings can be used to inform family support services and highlight the need to augment public assistance programs with services aimed to also address maternal psychological well-being and social support. Doing so can be a means of improving the public and private safety nets and outcomes of vulnerable families.

The effect of welfare reform on the health of the unemployed: evidence from a natural experiment in Germany

BACKGROUND

Over the past several decades, governments have enacted far-reaching reforms aimed at reducing the generosity and coverage of welfare benefits. Prior literature suggests that these policy measures may have deleterious effects on the health of populations. In this study, we evaluate the impact of one of the largest welfare reforms in recent history-the 2005 Hartz IV reform in Germany-with a focus on estimating its effect on the health of the unemployed.

METHODS

We employed a quasi-experimental difference-in-differences (DID) design using population-based data from the German Socio-Economic Panel Study, covering the period between 1994 and 2016. We applied DID linear probability modelling to examine the association between the Hartz IV reform and poor self-rated health, adjusting for a range of demographic and socioeconomic confounders.

RESULTS

The Hartz IV reform was associated with a 3.6 (95% CI 0.9 to 6.2) percentage point increase in the prevalence of poor self-rated health among unemployed persons affected by the reform relative to similar but unaffected controls. This negative association appeared immediately following the implementation of the reform and has persisted over time.

CONCLUSION

Governments in numerous European and North American jurisdictions have introduced measures to further diminish the generosity and coverage of welfare benefits. In line with growing concerns over the potential consequences of austerity and associated policy measures, our findings suggest that these reform efforts pose a threat to the health of socioeconomically disadvantaged populations.

The effects of poverty reduction policy on health services utilization among the rural poor: a quasi-experimental study in central and western rural China

Background

China poverty reduction policy (PRP) addresses two important elements: the targeted poverty reduction (TPA) project since 2015 in line with social assistance policy as national policy; and reducing inequality in health services utilization by making provision of medical financial assistance (MFA). Therefore, this study aims to assess the effects of the PRP in health services utilization (both inpatient and outpatient services) among the central and western rural poor of China.

Methods

The study conducted household survey and applied propensity score matching (PSM) method to assess the effects of the PRP on health services utilization among the rural poor of Central and Western China. A sensitivity test was also performed on the PSM results to test their robustness.

Results

Key findings showed 17.6% of respondents were the beneficial of PRP. The average treatment effects on the treated (ATT) of the PRP on the inpatient visits within one year was found significantly positive (P = 0.026).

Conclusion

There has been relationship between PRP with medical financial assistance and reduction of inequality in health services utilization by the poorer, in particular to accessing the inpatient services from the county or township hospitals of China. Policy makers should pay attention for making provision of improving responsiveness of supply, when subsidizing on the demand side.

Examining the relationship between U.S. incarceration rates and population health at the county level

A collateral consequence of mass incarceration in the United States is its negative effects on population health. Using data from 2015, this study examines the relationship between incarceration rates and population health for a national sample of U.S. counties. To obtain unbiased estimates of the effect of incarceration on health, we use multivariate models which account for the endogeneity of incarceration rates when determining their effect on population health by employing an instrumental variable approach where the robust instrumental (exogenous) variable per capita corrections expenditures is used to predict incarceration rate. We then estimate population health outcomes as a function of predicted incarceration rate alongside factors such as public health spending, indicators of health behavior and control variables in models explaining county-level population health. Consistent with findings from prior research on individuals, families and at the state level, results of our analyses indicate that higher levels of incarceration are associated with higher levels of both morbidity (percentage reporting fair or poor health) and mortality (life expectancy). Implications of these findings for health and criminal justice policy, as well as research, are considered.