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Bhuwania P, Raub A, Sprague A, Martin A, Bose B, Kidman R, Nandi A, Behrman JR, Heymann J. Impact of laws prohibiting domestic violence on wasting in early childhood. PLoS One 2024; 19:e0301224. [PMID: 38547244 PMCID: PMC10977741 DOI: 10.1371/journal.pone.0301224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 03/12/2024] [Indexed: 04/02/2024] Open
Abstract
Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.
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Affiliation(s)
- Pragya Bhuwania
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Amy Raub
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Aleta Sprague
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Alfredo Martin
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Bijetri Bose
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Rachel Kidman
- Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, New York, United States of America
| | - Arijit Nandi
- Department of Epidemiology, Biostatistics and Occupational Health and the Institute for Health and Social Policy, Montreal, Quebec, Canada
| | - Jere R. Behrman
- Department of Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jody Heymann
- WORLD Policy Analysis Center, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America
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Venkataramani AS. Affirmative Action, Population Health, and the Importance of Opportunity and Hope. N Engl J Med 2023; 389:1157-1159. [PMID: 37672691 DOI: 10.1056/nejmp2307766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Atheendar S Venkataramani
- From the Department of Medical Ethics and Health Policy, Perelman School of Medicine, the Leonard Davis Institute of Health Economics, and the Opportunity for Health Lab, University of Pennsylvania, Philadelphia
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Ly DP, Essien UR, Olenski AR, Jena AB. Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools. Ann Intern Med 2022; 175:873-878. [PMID: 35500257 DOI: 10.7326/m21-4312] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The percentage of U.S. physicians who identify as being from an underrepresented racial or ethnic group remains low relative to their proportion in the U.S. population. How this percentage may have been affected by state bans on affirmative action in public postsecondary institutions has received relatively little attention. OBJECTIVE To examine the association between state affirmative action bans and percentage of enrollment in U.S. public medical schools from underrepresented racial and ethnic groups. DESIGN Event study comparing public medical schools in states that implemented affirmative action bans with those in states without bans. SETTING U.S. public medical schools. PARTICIPANTS 21 public medical schools in 8 states with affirmative action bans matched to 32 public medical schools in 24 states without bans from 1985 to 2019. MEASUREMENTS Percentage of total enrollment from racial and ethnic groups underrepresented in medicine (Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander). RESULTS The percentage of enrollment from underrepresented racial and ethnic groups was 14.8% in U.S. public medical schools in the year before ban implementation in states with bans. The adjusted percentage of underrepresented students in ban schools decreased by 4.8 percentage points (95% CI, -6.3 to -3.2 percentage points) 5 years after ban implementation relative to the year before implementation, whereas the adjusted percentage in control schools increased by 0.7 percentage point (CI, -0.1 to 1.6 percentage points), for a relative difference, or difference-in-differences estimate, of -5.5 percentage points (CI, -7.1 to -3.9 percentage points). LIMITATION Inability to account for the effect of these bans on undergraduate enrollment. CONCLUSION State affirmative action bans were associated with significant reductions in the percentage of students in U.S. public medical schools from underrepresented racial and ethnic groups. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Dan P Ly
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California (D.P.L.)
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (U.R.E.)
| | - Andrew R Olenski
- Department of Economics, Columbia University, New York, New York (A.R.O.)
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, Department of Medicine, Massachusetts General Hospital, Boston, and National Bureau of Economic Research, Cambridge, Massachusetts (A.B.J.)
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Unger ES, Grabowski DC, Chen JT, Berkman LF. Association Between New-Onset Medicaid Home Care and Family Caregivers' Health. JAMA HEALTH FORUM 2021; 2:e212671. [PMID: 35977187 PMCID: PMC8796991 DOI: 10.1001/jamahealthforum.2021.2671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/23/2021] [Indexed: 12/22/2022] Open
Abstract
Importance More than 17 million people in the US provide uncompensated care for adults with physical or cognitive limitations. Such caregiving is associated with worse mental and physical health, yet little research has investigated how publicly funded home care might ameliorate these harms. Objective To investigate the association between Medicaid home care services and family caregivers' health. Design Setting and Participants This longitudinal cohort study used data from the 1996 to 2017 Medical Expenditures Panel Survey. Data on all household members were collected in 5 interviews over 2 years. Person-level difference-in-difference models were used to isolate within-person changes associated with new onset of Medicaid home care. The Medical Expenditures Panel Survey longitudinal data sets included 331 202 individuals (approximately 10% excluded owing to loss to follow-up). Adult (age ≥21 years) members of households that contained at least 1 person with limited activities of daily living were included in our study. The analysis itself was performed from March to August of 2020. Exposures New onset of regular (≥1 time per month) Medicaid home care in the household. Main Outcomes and Measures Self-rated mental and physical health (planned prior to beginning the study). Results The study population was 14 013 adults; 7232 were "likely caregivers," or nondisabled adult coresidents of someone with activities of daily living limitations. Overall, 962 likely caregivers were ever exposed to Medicaid home care in the household; for 563, we observed the onset. Of likely caregivers exposed to Medicaid home care, 479 (50%) were women; 296 (31%) were White non-Hispanic, 309 (31%) were Hispanic or Latinx, and 279 (29%) were Black non-Hispanic individuals, respectively; 326 (34%) had less than a high school education; and 300 (31%) were in or near poverty. Median age of participants was 51 (interquartile range, 39-62) years. New-onset Medicaid home care was associated with a 0.08 standard deviation improvement in likely caregivers' self-rated mental health (95% CI, 0.01-0.14; P = .02) measured 1 to 6 months after onset, equivalent to a 3.39% improvement (95% CI, 0.05%-6.33%) over their average preonset mental health. No association with self-rated physical health was found (<0.001 standard deviations; 95% CI, -0.06 to 0.06; P = .99). Conclusions and Relevance In this cohort study, Medicaid home care was associated with improvement in caregiver self-rated mental health, but not with any short-term change in self-rated physical health. When evaluating the social value of home care programs, policy makers should consider spillover benefits to caregivers.
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Affiliation(s)
- Emily S Unger
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jarvis T Chen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lisa F Berkman
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Vable AM, Duarte CDP, Wannier SR, Chan-Golston AM, Cohen AK, Glymour MM, Ream RK, Yen IH. Understanding the benefits of different types and timing of education for mental health: A sequence analysis approach. J Gerontol B Psychol Sci Soc Sci 2021; 79:gbab147. [PMID: 34387339 PMCID: PMC10935480 DOI: 10.1093/geronb/gbab147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Individuals increasingly experience delays or interruptions in schooling; we evaluate the association between these non-traditional education trajectories and mental health. METHODS Using year-by-year education data for 7,501 National Longitudinal Survey of Youth 1979 participants, ages 14-48 (262,535 person-years of education data), we applied sequence analysis and a clustering algorithm to identify educational trajectory groups, incorporating both type and timing to credential. Linear regression models, adjusted for early-life confounders, evaluated relationships between educational trajectories and mental health component scores (MCS) from the 12-item short form instrument at age 50. We evaluated effect modification by race, gender, and race by gender. RESULTS We identified 24 distinct educational trajectories based on highest credential and educational timing. Compared to high school (HS) diplomas, < HS (beta=-3.41, 95%CI:-4.74,-2.07) and general educational development credentials (GEDs) predicted poorer MCS (beta=-2.07,95%CI:-3.16,-0.98). The following educational trajectories predicted better MCS: some college immediately after High School (beta=1.52, 95%CI:0.68,2.37), Associate degrees after long interruptions (beta=1.73, 95%CI:0.27,3.19), and graduate school soon after Bachelor's completion (beta=1.13, 95%CI:0.21,2.06). Compared to White men, Black women especially benefited from educational credentials higher than HS in predicting MCS. CONCLUSIONS Both type and timing of educational credential predicted mental health. Black women's mental higher especially benefited from higher educational credentials.
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Affiliation(s)
- Anusha M Vable
- Department of Family and Community Medicine, University of California San Francisco, USA
| | | | - S Rae Wannier
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - Alec M Chan-Golston
- Department of Public Health, School of Social Sciences, Humanities and Arts, University of California Merced, USA
| | - Alison K Cohen
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - Robert K Ream
- Graduate School of Education, University of California Riverside, USA
| | - Irene H Yen
- Department of Public Health, School of Social Sciences, Humanities and Arts, University of California Merced, USA
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Yu S, Sohn H, Kim HY, Kim H, Oh KH, Kim HJ, Chung H, Choi H. Evaluating the impact of the nationwide public-private mix (PPM) program for tuberculosis under National Health Insurance in South Korea: A difference in differences analysis. PLoS Med 2021; 18:e1003717. [PMID: 34260579 PMCID: PMC8318235 DOI: 10.1371/journal.pmed.1003717] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 07/28/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Public-private mix (PPM) programs on tuberculosis (TB) have a critical role in engaging and integrating the private sector into the national TB control efforts in order to meet the End TB Strategy targets. South Korea's PPM program can provide important insights on the long-term impact and policy gaps in the development and expansion of PPM as a nationwide program. METHODS AND FINDINGS Healthcare is privatized in South Korea, and a majority (80.3% in 2009) of TB patients sought care in the private sector. Since 2009, South Korea has rapidly expanded its PPM program coverage under the National Health Insurance (NHI) scheme as a formal national program with dedicated PPM nurses managing TB patients in both the private and public sectors. Using the difference in differences (DID) analytic framework, we compared relative changes in TB treatment outcomes-treatment success (TS) and loss to follow-up (LTFU)-in the private and public sector between the 2009 and 2014 TB patient cohorts. Propensity score matching (PSM) using the kernel method was done to adjust for imbalances in the covariates between the 2 population cohorts. The 2009 cohort included 6,195 (63.0% male, 37.0% female; mean age: 42.1) and 27,396 (56.1% male, 43.9% female; mean age: 45.7) TB patients in the public and private sectors, respectively. The 2014 cohort included 2,803 (63.2% male, 36.8% female; mean age: 50.1) and 29,988 (56.5% male, 43.5% female; mean age: 54.7) patients. In both the private and public sectors, the proportion of patients with transfer history decreased (public: 23.8% to 21.7% and private: 20.8% to 17.6%), and bacteriological confirmed disease increased (public: 48.9% to 62.3% and private: 48.8% to 58.1%) in 2014 compared to 2009. After expanding nationwide PPM, absolute TS rates improved by 9.10% (87.5% to 93.4%) and by 13.6% (from 70.3% to 83.9%) in the public and private sectors. Relative to the public, the private saw 4.1% (95% confidence interval [CI] 2.9% to 5.3%, p-value < 0.001) and -8.7% (95% CI -9.7% to -7.7%, p-value <0.001) higher rates of improvement in TS and reduction in LTFU. Treatment outcomes did not improve in patients who experienced at least 1 transfer during their TB treatment. Study limitations include non-longitudinal nature of our original dataset, inability to assess the regional disparities, and verify PPM program's impact on TB mortality. CONCLUSIONS We found that the nationwide scale-up of the PPM program was associated with improvements in TB treatment outcomes in the private sector in South Korea. Centralized financial governance and regulatory mechanisms were integral in facilitating the integration of highly diverse South Korean private sector into the national TB control program and scaling up of the PPM intervention nationwide. However, TB care gaps continued to exist for patients who transferred at least once during their treatment. These programmatic gaps may be improved through reducing administrative hurdles and making programmatic amendments that can help facilitate management TB patients between institutions and healthcare sectors, as well as across administrative regions.
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Affiliation(s)
- Sarah Yu
- Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea
- School of Health Policy & Management, College of Health Science, Korea University, Seoul, Republic of Korea
- BK21 FOUR R&E Center for Learning Health Systems, Korea University, Seoul, Republic of Korea
| | - Hojoon Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Hae-Young Kim
- School of Health Policy & Management, College of Health Science, Korea University, Seoul, Republic of Korea
- BK21 FOUR R&E Center for Learning Health Systems, Korea University, Seoul, Republic of Korea
| | - Hyunwoo Kim
- Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kyung-Hyun Oh
- Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea
- End TB and Leprosy Unit, World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Hee-Jin Kim
- Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea
| | - Haejoo Chung
- School of Health Policy & Management, College of Health Science, Korea University, Seoul, Republic of Korea
- BK21 FOUR R&E Center for Learning Health Systems, Korea University, Seoul, Republic of Korea
| | - Hongjo Choi
- Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Republic of Korea
- Department of Preventive Medicine, College of Medicine, Konyang University, Daejeon, Republic of Korea
- * E-mail:
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Raifman J, Bor J, Venkataramani A. Association Between Receipt of Unemployment Insurance and Food Insecurity Among People Who Lost Employment During the COVID-19 Pandemic in the United States. JAMA Netw Open 2021; 4:e2035884. [PMID: 33512519 PMCID: PMC7846943 DOI: 10.1001/jamanetworkopen.2020.35884] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/11/2020] [Indexed: 11/22/2022] Open
Abstract
Importance More than 50 million US residents have lost work during the coronavirus disease 2019 (COVID-19) pandemic, and food insecurity has increased. Objective To evaluate the association between receipt of unemployment insurance, including a $600/wk federal supplement between April and July, and food insecurity among people who lost their jobs during the COVID-19 pandemic. Design, Setting, and Participants This cohort study used difference-in-differences analysis of longitudinal data from a nationally representative sample of US adults residing in low- and middle-income households (ie, <$75 000 annual income) who lost work during the COVID-19 pandemic. Data were from 15 waves of the Understanding Coronavirus in America study (conducted April 1 to November 11, 2020). Exposure Receipt of unemployment insurance benefits. Main Outcomes and Measures Food insecurity and eating less due to financial constraints, assessed every 2 weeks by self-report. Results Of 2319 adults living in households earning less than $75 000 annually and employed in February 2020, 1119 (48.3%) experienced unemployment during the COVID-19 pandemic and made up our main sample (588 [53.6%] White individuals; mean [SD] age 45 [15] years; 732 [65.4%] women). Of those who lost employment, 415 (37.1%) reported food insecurity and 437 (39.1%) reported eating less due to financial constraints in 1 or more waves of the study. Among people who lost work, receipt of unemployment insurance was associated with a 4.3 (95% CI, 1.8-6.9) percentage point decrease in food insecurity (a 35.0% relative reduction) and a 5.7 (95% CI, 3.0-8.4) percentage point decrease in eating less due to financial constraints (a 47.8% relative reduction). Decreases in food insecurity were larger with the $600/wk supplement and for individuals who were receiving larger amounts of unemployment insurance. Conclusions and Relevance In this US national cohort study, receiving unemployment insurance was associated with large reductions in food insecurity among people who lost employment during the COVID-19 pandemic. The $600/wk federal supplement and larger amounts of unemployment insurance were associated with larger reductions in food insecurity.
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Affiliation(s)
- Julia Raifman
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Atheendar Venkataramani
- Leonard Davidson Institute for Health Economics, University of Pennsylvania, Philadelphia
- Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Vable AM, Duarte CDP, Cohen AK, Glymour MM, Ream RK, Yen IH. Does the Type and Timing of Educational Attainment Influence Physical Health? A Novel Application of Sequence Analysis. Am J Epidemiol 2020; 189:1389-1401. [PMID: 32676653 DOI: 10.1093/aje/kwaa150] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 11/14/2022] Open
Abstract
Nontraditional education trajectories are common, but their influence on physical health is understudied. We constructed year-by-year education trajectories for 7,501 National Longitudinal Survey of Youth 1979 participants aged 14 to 48 years (262,535 person-years of education data from 1979 to 2014). We characterized trajectory similarity using sequence analysis and used hierarchical clustering to group similar educational trajectories. Using linear regression, we predicted physical health summary scores of the participants at age 50 years from the 12-item Short-Form Survey, adjusting for available confounders, and evaluated effect modification by sex, race/ethnicity, and childhood socioeconomic status. We identified 24 unique educational sequence clusters on the basis of highest level of schooling and attendance timing. General education development credentials predicted poorer health than did high school diplomas (β = -3.07, 95% confidence interval: -4.07, -2.07), and bachelor's degrees attained at earlier ages predicted better health than the same degree attained at later ages (β = 1.66, 95% confidence interval: 0.05, 3.28). Structurally marginalized groups benefited more from some educational trajectories than did advantaged groups (e.g., Black vs. White Americans with some college; those of low vs. high childhood socioeconomic status who received an associate's or bachelor's degree). Both type and timing of educational credentials may influence physical health. Literature to date has likely underestimated the impact of educational trajectories on health.
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Venkataramani AS, O’Brien R, Whitehorn GL, Tsai AC. Economic influences on population health in the United States: Toward policymaking driven by data and evidence. PLoS Med 2020; 17:e1003319. [PMID: 32877406 PMCID: PMC7467305 DOI: 10.1371/journal.pmed.1003319] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Rourke O’Brien
- Department of Sociology, Yale University, New Haven, Connecticut, United States of America
| | - Gregory L. Whitehorn
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Alexander C. Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
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State-level prescription drug monitoring program mandates and adolescent injection drug use in the United States, 1995-2017: A difference-in-differences analysis. PLoS Med 2020; 17:e1003272. [PMID: 32976539 PMCID: PMC7518580 DOI: 10.1371/journal.pmed.1003272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prescription opioid misuse is an ongoing crisis and a risk factor for injection drug use (IDU). Few studies have evaluated strategies for preventing opioid or IDU initiation among adolescents. We evaluated changes in the proportion of adolescents reporting IDU before and after prescription drug monitoring program (PDMP) mandates were implemented in 18 states compared to 29 states without such mandates. METHODS AND FINDINGS This difference-in-differences analysis used biannual Youth Risk Behavioral Surveillance System (YRBSS) data representative of adolescents 17 to 18 years old across 47 states from 1995 to 2017. We compared changes in adolescent IDU in 18 states with and 29 states without PDMP mandates. Among 331,025 adolescents, 51.7% identified as male, 62.1% as non-Hispanic white, 17.4% as non-Hispanic black, and 14.6% as Hispanic. Overall, 3.5% reported IDU during the 2 years prior to PDMP mandates. In the final multivariable difference-in-differences model, we included individual age, sex, and race/ethnicity, as well as state and year as covariates from the YRBSS. We also included state- and year-specific poverty rates based on US Census Bureau data. Additionally, we controlled for state implementation of (non-mandated) PDMPs before states subsequently implemented mandates and pill mill laws. We conducted several sensitivity analyses, including repeating our main analysis using a logistic, rather than linear, model, and with a lead indicator on PDMP mandate implementation, a lag indicator, and alternative policy implementation dates. PDMP mandates were associated with a 1.5 percentage point reduction (95% CI -2.3 to -0.6 percentage points; p = 0.001) in adolescent IDU, on average over the years following mandate implementation, a relative reduction of 42.9% (95% CI -65.7% to -17.1%). The association of PDMP mandates with this reduction persisted at least 4 years beyond implementation. Sensitivity analyses were consistent with the main results. Limitations include the multi-stepped causal pathway from PDMP mandate implementation to changes in IDU and the potential for omitted state-level time-varying confounders. CONCLUSIONS Our analysis indicated that PDMP mandates were associated with a reduction in adolescent IDU, providing empirical evidence that such mandates may prevent adolescents from initiating IDU. Policymakers might consider PDMP mandates as a potential strategy for preventing adolescent IDU.
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Raifman J, Bor J, Venkataramani A. Unemployment insurance and food insecurity among people who lost employment in the wake of COVID-19. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32766606 PMCID: PMC7402065 DOI: 10.1101/2020.07.28.20163618] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Forty million U.S. residents lost their jobs in the first two months of the coronavirus disease 2019 (COVID-19) pandemic. In response, the Federal Government expanded unemployment insurance benefits in both size ($600/week supplement) and scope (to include caregivers and self-employed workers). We assessed the relationship between unemployment insurance and food insecurity among people who lost their jobs during the COVID-19 pandemic in the period when the federal unemployment insurance supplement was in place. We analyzed data from the Understanding Coronavirus in America (UAC) cohort, a longitudinal survey collected by the University of Southern California Center for Economic and Social Research (CESR) every two weeks between April 1 and July 8, 2020. We limited the sample to individuals living in households earning less than $75,000 in February 2020 who lost their jobs during COVID-19. Using difference-in-differences and event study regression models, we evaluated the association between receipt of unemployment insurance and self-reported food insecurity and eating less due to financial constraints. We found that 40.5% of those living in households earning less than $75,000 and employed in February 2020 experienced unemployment during the COVID-19 pandemic. Of those who lost their jobs, 31% reported food insecurity and 33% reported eating less due to financial constraints. Food insecurity peaked in April 2020 and declined over time, but began to increase again among people receiving unemployment insurance during the final wave of the survey ahead of the federal supplement to unemployment insurance ending. Food insecurity and eating less were more common among people who were non-White, lived in lower-income households, younger, and who were sexual or gender minorities. Receipt of unemployment insurance was associated with a 4.4 percentage point (95% CI: −7.8 to −0.9 percentage points) decline in food insecurity (a 30.3% relative decline compared to the average level of food insecurity during the study period). Receipt of unemployment insurance was also associated with a 6.1 percentage point (95% CI: −9.6 to −2.7 percentage point) decline in eating less due to financial constraints (a 42% relative decline). Estimates from event study specifications revealed that reductions in food insecurity and eating less were greatest in the four-week period immediately following receipt of unemployment insurance, with no evidence of differential pre-existing trends in either outcome. We conclude that receiving unemployment insurance benefits during the period when the $600/week federal supplement was in place was associated with large reductions in food insecurity.
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Affiliation(s)
- Julia Raifman
- Department of Health Law, Policy & Management, Boston University School of Public Health
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health
| | - Atheendar Venkataramani
- Medical Ethics and Health Policy, Leonard Davidson Institute for Health Economics, Center for Health Incentives & Behavioral Economics, University of Pennsylvania
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Raifman J, Larson E, Barry CL, Siegel M, Ulrich M, Knopov A, Galea S. State handgun purchase age minimums in the US and adolescent suicide rates: regression discontinuity and difference-in-differences analyses. BMJ 2020; 370:m2436. [PMID: 32699008 PMCID: PMC7374798 DOI: 10.1136/bmj.m2436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the association between US state policies that establish age 18 or 21 years as the minimum purchaser age for the sale of handguns and adolescent suicide rate. DESIGN Regression discontinuity and difference-in-differences analyses. SETTING 46 US states without policy changes between 2001 and 2017; Missouri and South Carolina, which lowered the age for handgun sales in 2007 and 2008, respectively; and West Virginia and Wyoming, which increased the age for handgun sales in 2010. PARTICIPANTS Adolescents aged 13 to 20 years(554 461 961 from 2001 to 2017) in the regression discontinuity analysis, and adolescents aged 18 to 20 years (168 934 041 from 2002 to 2014) in the main difference-in-differences analysis. MAIN OUTCOME MEASURE Suicide rate per 100 000 adolescents. RESULTS In the regression discontinuity analysis, state policies that limited the sale of handguns to those aged 18 or older (relative to 21 or older) were associated with an increase in suicide rate among adolescents aged 18 to 20 years equivalent to 344 additional suicides in each state where they were in place between 2001 and 2017. In the difference-in-differences analysis, state policies that limited the sale of handguns to those aged 21 or older were associated with 1.91 fewer suicides per 100 000 adolescents aged 18 to 20 years (95% confidence interval -3.13 to -0.70, permutation adjusted P=0.025). In the difference-in-differences analysis, there were 1.83 fewer firearm related suicides per 100 000 adolescents (-2.66 to -1.00, permutation adjusted P=0.002), with no association between age 21 handgun sales policies and non-firearm related suicides. Separate event study estimates indicated increases in suicide rates in states that lowered the age of handgun sales, with no association in states that increased the age of handgun sales. CONCLUSIONS A clear discontinuity was shown in the suicide rate by age at age 18 in states that limited the sale of handguns to individuals aged 18 or older. State policies to limit the sale of handguns to individuals aged 21 or older were associated with a reduction in suicide rates among adolescents. Increases in suicide rates were observed after states lowered the age of handgun sales, but no effect was found in states that increased the age of handgun sales.
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Affiliation(s)
- Julia Raifman
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA 02118, USA
| | - Elysia Larson
- Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Colleen L Barry
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Siegel
- Boston University School of Public Health, Boston, MA, USA
| | - Michael Ulrich
- Boston University School of Public Health, Boston, MA, USA
| | - Anita Knopov
- Brown University Department of Emergency Medicine, Providence, RI, USA
| | - Sandro Galea
- Boston University School of Public Health, Boston, MA, USA
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School academic climate and oral health (tooth loss) in adolescents. PLoS One 2020; 15:e0233505. [PMID: 32437411 PMCID: PMC7241719 DOI: 10.1371/journal.pone.0233505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background Preventing tooth loss depends on oral health maintenance behaviors. This study hypothesized that adolescents with educational aspirations have greater motivation to invest in the future, including maintenance of oral health status. Aim To analyze the association between a school academic climate of educational aspirations and tooth loss (first permanent molars) among adolescents. Methods A cross-sectional study was designed to include 2,500 adolescents (aged 14–19 years) enrolled in public high schools of Olinda located in Northeast Brazil. Multilevel Poisson regression random intercept models were conducted with tooth loss (first permanent molars) as the outcome. The primary cohort of interest was school academic climate, as measured by the proportion of students taking the national high school exams. Results Tooth loss of the first permanent molars (assessed by clinical exam) was more prevalent in adolescents from more disadvantaged backgrounds (receiving family allowance, low maternal education). However, after controlling for a wide range of individual characteristics, adolescents enrolled in schools with lower academic climate had a higher prevalence of tooth loss (PR 1.42, 95%CI: 1.09,1.85). Conclusion The school academic climate is associated with tooth loss, suggesting that educational aspirations are linked to adolescent oral health maintenance behaviors.
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Venkataramani A, Daza S, Emanuel E. Association of Social Mobility With the Income-Related Longevity Gap in the United States: A Cross-Sectional, County-Level Study. JAMA Intern Med 2020; 180:429-436. [PMID: 31961379 PMCID: PMC6990844 DOI: 10.1001/jamainternmed.2019.6532] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
IMPORTANCE Despite substantial research, the drivers of the widening gap in life expectancy between rich and poor individuals in the United States-known as the longevity gap-remain unknown. The hypothesis of this study is that social mobility may play an important role in explaining the longevity gap. OBJECTIVE To assess whether social mobility is associated with income-related differences in life expectancy in the United States. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, ecological study used data from 1559 counties in the United States to assess the association of social mobility with average life expectancy at age 40 years by sex and income quartile among adult men and women over the period of January 2000 through December 2014. Bayesian generalized linear multilevel regression models were used to estimate the association, with adjustment for a range of socioeconomic, demographic, and health care system characteristics. EXPOSURES County-level social mobility, here operationalized as the association of the income rank of individuals born during the period of January 1980 through December 1982 (based on tax record data, averaged over the period January 2010 through December 2012) with the income ranks of their parents (averaged over the period January 1996 through December 2000) using the location where the parent first claimed the child as a dependent at age 15 years to identify counties. MAIN OUTCOMES AND MEASURES The main outcome was life expectancy at age 40 years by sex and income quartile. RESULTS The sample consisted of 1559 counties, which represented 93% of the US population in 2000. Each 1-SD increase in social mobility-equivalent to the difference between a low-mobility state, such as Alabama (ranked 49th on this measure), and a higher-mobility state, such as Massachusetts (ranked 23rd on this measure)-was associated with a 0.38-year (95% credible interval [CrI], 0.29-0.47) and a 0.29-year (95% CrI, 0.21-0.38) increase in county-level life expectancy among men and women, respectively, in the lowest income quartile. Estimates for life expectancies among county residents in the highest income quartile were smaller in magnitude and not robust to covariate adjustment (men: 0.10-year [95% CrI, -0.02 to 0.22] increase; women: 0.08-year [95% CrI, -0.05 to 0.20] increase). Increasing social mobility in all counties to the value of the highest social mobility county was associated with decreases in the life expectancy gap between the highest and lowest income quartiles by 1.4 (95% CrI, 0.7-2.1) years for men and 1.1 (95% CrI, 0.5-1.6) years for women nationally, representing a 20% decrease. CONCLUSIONS AND RELEVANCE In this cross-sectional study, higher county-level social mobility was associated with smaller county-level gaps in life expectancy by income. These findings motivate further investigation of causal relationships between policies that shift social mobility and health outcomes.
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Affiliation(s)
- Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Sebastian Daza
- Center for Demography and Ecology, University of Wisconsin-Madison.,Department of Sociology, University of Wisconsin-Madison
| | - Ezekiel Emanuel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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