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Wang G, Hamad R, White JS. Advances in Difference-in-differences Methods for Policy Evaluation Research. Epidemiology 2024; 35:628-637. [PMID: 38968376 PMCID: PMC11305929 DOI: 10.1097/ede.0000000000001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 05/21/2024] [Indexed: 07/07/2024]
Abstract
Difference-in-differences (DiD) is a powerful, quasi-experimental research design widely used in longitudinal policy evaluations with health outcomes. However, DiD designs face several challenges to ensuring reliable causal inference, such as when policy settings are more complex. Recent economics literature has revealed that DiD estimators may exhibit bias when heterogeneous treatment effects, a common consequence of staggered policy implementation, are present. To deepen our understanding of these advancements in epidemiology, in this methodologic primer, we start by presenting an overview of DiD methods. We then summarize fundamental problems associated with DiD designs with heterogeneous treatment effects and provide guidance on recently proposed heterogeneity-robust DiD estimators, which are increasingly being implemented by epidemiologists. We also extend the discussion to violations of the parallel trends assumption, which has received less attention. Last, we present results from a simulation study that compares the performance of several DiD estimators under different scenarios to enhance understanding and application of these methods.
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Affiliation(s)
- Guangyi Wang
- From the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, CA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rita Hamad
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Justin S White
- From the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, CA
- Department of Health Law, Policy & Management, Boston University, Boston, MA
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Faugno E, Gilkey MB, Cripps L, Kennedy KL, Eftekhari S, Galbraith AA. "No room for error": a qualitative interview study of experiences with health insurance coverage loss and COVID-19 pandemic relief policies among people with asthma. J Asthma 2024:1-10. [PMID: 39093725 DOI: 10.1080/02770903.2024.2387759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES The COVID-19 pandemic led to unemployment and associated health insurance loss, prompting an unprecedented adoption of emergency policies, including economic relief efforts and health insurance coverage expansion. We sought to understand pandemic-related challenges for people with asthma and how emergency policies served families facing both chronic disease management and health insurance loss. STUDY DESIGN Qualitative interview study. METHODS In 2021, we conducted semi-structured telephone interviews with 21 adults who had asthma and lost employment and employer-sponsored health insurance coverage during the COVID-19 pandemic. We used thematic analysis to assess how health and economic policies affected participants' ability to access care and manage their asthma. RESULTS Participants reported reduced access to care, as well as worry about heightened susceptibility to COVID-19 due to their asthma. While insurance loss exacerbated these challenges, participants indicated that economic relief efforts, including direct stimulus payments, helped them afford needed asthma care. Participants were more critical of enhancements to existing coverage policies such as the Affordable Care Act (ACA) Marketplace and Consolidated Omnibus Budget Reconciliation Act (COBRA) due to difficulty understanding, accessing, and affording such coverage. CONCLUSIONS Our findings underscore that people affected by asthma and health insurance loss benefit from policies that provide flexible and easy-to-use assistance, such as direct payments, for meeting the diverse challenges posed by living with a chronic disease. Although policies that expand health insurance coverage are critical, more attention is needed to help people with chronic conditions access these programs in a timely way.
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Affiliation(s)
- Elena Faugno
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Melissa B Gilkey
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA
| | - Lauren Cripps
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Kathryn L Kennedy
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA
| | - Sanaz Eftekhari
- Allergy and Asthma Foundation of America, Arlington, VA, USA
| | - Alison A Galbraith
- Department of Pediatrics, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
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Ogunbameru A, Gebretekle GB, Perryman A, Hassan M, Farrell A, Liu K, Mishra S, Sander B. Health and non-health benefits and equity impacts of individual-level economic relief programs during epidemics/pandemics in high income settings: a scoping review. BMC Public Health 2024; 24:2106. [PMID: 39103834 DOI: 10.1186/s12889-024-19493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 07/15/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Economic relief programs are strategies designed to sustain societal welfare and population health during a regional or global scale infectious disease outbreak. While economic relief programmes are considered essential during a regional or global health crisis, there is no clear consensus in the literature about their health and non-health benefits and their impact on promoting equity. METHODS We conducted a scoping review, searching eight electronic databases from January 01, 2001, to April 3, 2023, using text words and subject headings for recent pathogens (coronavirus (COVID-19), Ebola, Influenza, Middle East Respiratory Syndrome (MERS), severe acute respiratory syndrome (SARS), HIV, West Nile, and Zika), and economic relief programs; but restricted eligibility to high-income countries and selected diseases due to volume. Title and abstract screening were conducted by trained reviewers and Distiller AI software. Data were extracted in duplicates by two trained reviewers using a pretested form, and key findings were charted using a narrative approach. RESULTS We identified 27,263 de-duplicated records, of which 50 were eligible. Included studies were on COVID-19 and Influenza, published between 2014 and 2023. Zero eligible studies were on MERS, SARS, Zika, Ebola, or West Nile Virus. We identified seven program types of which cash transfer (n = 12) and vaccination or testing incentive (n = 9) were most common. Individual-level economic relief programs were reported to have varying degrees of impact on public health measures, and sometimes affected population health outcomes. Expanding paid sick leave programs had the highest number of studies reporting health-related outcomes and positively impacted public health measures (isolation, vaccination uptake) and health outcomes (case counts and the utilization of healthcare services). Equity impact was most often reported for cash transfer programs and incentive for vaccination programs. Positive effects on general well-being and non-health outcomes included improved mental well-being and quality of life, food security, financial resilience, and job security. CONCLUSIONS Our findings suggest that individual-level economic relief programs can have significant impacts on public health measures, population health outcomes and equity. As countries prepare for future pandemics, our findings provide evidence to stakeholders to recognize health equity as a fundamental public health goal when designing pandemic preparedness policies.
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Affiliation(s)
- Adeteju Ogunbameru
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada.
| | - Gebremedhin Beedemariam Gebretekle
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
| | - Adrianna Perryman
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
- School of Global Health, York University - Keele Campus, Toronto, ON, Canada
| | - Marian Hassan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
| | - Ashley Farrell
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharmistha Mishra
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, ON, Canada
- Centre of Urban Health Solutions, St, Michael's Hospital, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Agarwal SD, Cook BL, Liebman JB. Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study. JAMA 2024:2821454. [PMID: 39037892 PMCID: PMC11264063 DOI: 10.1001/jama.2024.13004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/11/2024] [Indexed: 07/24/2024]
Abstract
Importance Poverty is associated with greater barriers to health care and worse health outcomes, but it remains unclear whether income support can improve health. Objective To examine the effect of cash benefits on health care utilization and health. Design, Setting, and Participants The City of Chelsea, Massachusetts, a low-income community near Boston, randomly assigned individuals by lottery to receive cash benefits. Participants' medical records were linked across multiple health systems. Outcomes were assessed during the intervention period from November 24, 2020, to August 31, 2021. Intervention Cash benefits via debit card of up to $400 per month for 9 months. Main Outcomes and Measures The primary outcome was emergency department visits. Secondary outcomes included specific types of emergency department visits, outpatient use overall and by specialty, COVID-19 vaccination, and biomarkers such as cholesterol levels. Results Among 2880 individuals who applied for the lottery, mean age was 45.1 years and 77% were female. The 1746 participants randomized to receive the cash benefits had significantly fewer emergency department visits compared with the control group (217.1 vs 317.5 emergency department visits per 1000 persons; adjusted difference, -87.0 per 1000 persons [95% CI, -160.2 to -13.8]). This included reductions in emergency department visits related to behavioral health (-21.6 visits per 1000 persons [95% CI, -40.2 to -3.1]) and substance use (-12.8 visits per 1000 persons [95% CI, -25.0 to -0.6]) as well as those that resulted in a hospitalization (-27.3 visits per 1000 persons [95% CI, -53.6 to -1.1]). The cash benefit had no statistically significant effect on total outpatient visits (424.3 visits per 1000 persons [95% CI, -118.6 to 967.2]), visits to primary care (-90.4 visits per 1000 persons [95% CI, -308.1 to 127.2]), or outpatient behavioral health (83.5 visits per 1000 persons [95% CI, -182.9 to 349.9]). Outpatient visits to other subspecialties were higher in the cash benefit group compared with the control group (303.1 visits per 1000 persons [95% CI, 32.9 to 573.2]), particularly for individuals without a car. The cash benefit had no statistically significant effect on COVID-19 vaccination, blood pressure, body weight, glycated hemoglobin, or cholesterol level. Conclusions and Relevance In this randomized study, individuals who received a cash benefit had significantly fewer emergency department visits, including those related to behavioral health and substance use, fewer admissions to the hospital from the emergency department, and increased use of outpatient subspecialty care. Study results suggest that policies that seek to alleviate poverty by providing income support may have important benefits for health and access to care.
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Affiliation(s)
- Sumit D. Agarwal
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Benjamin Lê Cook
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Jeffrey B. Liebman
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Ettman CK, Badillo-Goicoechea E, Stuart EA. Financial strain, schooling modality and mental health of US adults living with children during the COVID-19 pandemic. J Epidemiol Community Health 2024:jech-2023-221672. [PMID: 39019489 DOI: 10.1136/jech-2023-221672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 06/09/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The COVID-19 pandemic upended contexts for families; relatively little work has studied the influence of rapidly changing contexts on the mental health of parents. We aimed to assess the relation between financial strain and schooling modality with the mental health of adults living with school-age children across the pandemic. METHODS Using a large, national sample from the COVID-19 Trends and Impact Surveys (N=1 485 072 responses from November 2020 through June 2022), we used weighted multiple logistic regression with interactions for school semester to estimate changes in the association of frequent feelings of depression and anxiety, respectively, with financial strain and schooling modality, controlling for demographics and state, across time. RESULTS In all time periods, financial strain was associated with reporting frequent feelings of depression and anxiety, respectively. The association grew over time (p<0.001) from adjusted OR (aOR) 2.25 (95% CI 2.19, 2.32)/aOR 2.63 (95% CI 2.54, 2.73) in Autumn 2020 to aOR 3.11 (95% CI 3.01, 3.22)/aOR 3.79 (95% CI 3.64, 3.95) in Spring 2022. Living with children in fully online versus in-person schooling was associated with frequent feelings of anxiety and depression symptoms in all time periods, and increased from aOR 1.08 (1.05, 1.11)/aOR 1.06 (1.02, 1.10) in Autumn 2020 to aOR 1.20 (1.10, 1.32)/aOR 1.28 (1.16, 1.42) in Spring 2022. CONCLUSION Associations between financial strain and online-only schooling with poor mental health increased during the COVID-19 pandemic. Policies to support parents in the face of external stressors, such as economic instability and school closures, may improve overall population mental health.
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Affiliation(s)
- Catherine K Ettman
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elena Badillo-Goicoechea
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth A Stuart
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Yamanis TJ, Rao S, Reichert AJ, Haws R, Morrissey T, Suarez A. Dignity of Work and at Work: The Relationship between Workplace Dignity and Health among Latino Immigrants during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:855. [PMID: 39063431 PMCID: PMC11276970 DOI: 10.3390/ijerph21070855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/20/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024]
Abstract
Latino immigrants living in the United States were highly vulnerable to the health and economic consequences brought on by the COVID-19 pandemic. We use the conceptual framing of workplace dignity, worth that is acknowledged based on performance of job responsibilities, to explore Latino immigrants' experiences during the early months of the pandemic. A qualitative study was conducted with La Clínica del Pueblo (La Clínica), a community health center serving low-income Latino immigrants. From June to December 2020, we conducted in-depth video interviews with 29 Latino immigrant clients to explore pandemic-related challenges, including workplace changes, discriminatory experiences, and effects on health. We conducted thematic analysis using Dedoose software. Nearly half of participants were undocumented immigrants. Most participants were unemployed or underemployed due to the pandemic and 26-49 years of age; one-third were still working, and one-quarter were 50 years or older. About half were cisgender women and two were transgender women. Employed participants experienced a lack of dignity through being socially isolated and stigmatized at work; receiving no compensation for their extra labor or for sick leave; and experiencing discriminatory labor practices. Unemployed participants experienced a lack of dignity in being the first to lose their jobs without government support; losing self-esteem; and not being rehired. Participants associated denial of dignity with worsening health conditions and increased anxiety and depression. Our study suggests that denial of workplace dignity-through job loss, underemployment, and poor working conditions-is linked to adverse health outcomes for Latino immigrants. More research should recognize workplace dignity as an important social determinant of health.
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Affiliation(s)
- Thespina J. Yamanis
- School of International Service, American University, 4400 Massachusetts Ave. NW, Washington, DC 20016, USA;
| | - Samhita Rao
- School of International Service, American University, 4400 Massachusetts Ave. NW, Washington, DC 20016, USA;
| | - Alexandra J. Reichert
- Department of Anthropology, Vanderbilt University, 2301 Vanderbilt Place, Nashville, TN 37235, USA;
| | - Rachel Haws
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA;
| | - Taryn Morrissey
- School of Public Affairs, American University, 4400 Massachusetts Ave., Washington, DC 20016, USA;
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Adams E, Krovi A, Berquist A, Mosher P, Dugger R, Brickhouse T, Bean M. Perceived Impacts of the Expanded Child Tax Credit Cessation Based on Family Income Level. RESEARCH SQUARE 2024:rs.3.rs-4572262. [PMID: 38978594 PMCID: PMC11230495 DOI: 10.21203/rs.3.rs-4572262/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
The 2021 Expanded Child Tax Credit (ECTC) lifted millions of children out of poverty and drastically improved well-being. These impacts were particularly salient for families with lower income among those who received the full ECTC benefit. This study gathered lived experiences on the ECTC cessation and explored differential impacts across income levels to inform discussions around policy restoration. Semi-structured interviews were conducted with parents who had a child (2-12 years) who received the full ECTC. Interviews occurred in May 2022 after the ECTC ended. Changes in financial security and health were assessed. Families were classified as having lower vs. higher income (LI; n=19 vs. HI; n=19) corresponding to household income below vs. above 200% of the Federal Poverty Line. Inductive analysis and constant-comparison methods generated themes on similarities/differences between groups. Results indicated families with LI experienced severe financial constraints and greater negative emotions, after the ECTC ended. Many reduced spending, budgeted, accepted financial support from family/friends, and delayed credit card payments. More families with HI reported the ECTC provided a financial buffer placingthem in a more secure position to meet current needs. Both groups reported negative impacts from inflation coinciding with the ECTC ending and minimal changes in their income tax return. Families overwhelmingly reported a desire for the ECTC to continue, despite experiencing different degrees of impact due to these financial changes. Families with LI faced greater hardships after the ECTC ended. Differences across income highlight the need for ECTC restoration, particularly for families in severely under-resourced circumstances.
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Affiliation(s)
| | - Annika Krovi
- J.L. Mann Academy of Mathematics, Science, and Technology
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BERKOWITZ SETHA. Multisector Collaboration vs. Social Democracy for Addressing Social Determinants of Health. Milbank Q 2024; 102:280-301. [PMID: 38156764 PMCID: PMC11176409 DOI: 10.1111/1468-0009.12685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/13/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024] Open
Abstract
Policy Points Multisector collaboration, the dominant approach for responding to health harms created by adverse social conditions, involves collaboration among health care insurers, health care systems, and social services organizations. Social democracy, an underused alternative, seeks to use government policy to shape the civil (e.g., civil rights), political (e.g., voting rights), and economic (e.g., labor market institutions, property rights, and the tax-and-transfer system) institutions that produce health. Multisector collaboration may not achieve its goals, both because the collaborations are difficult to accomplish and because it does not seek to transform social conditions, only to mitigate their harms. Social democracy requires political contestation but has greater potential to improve population health and health equity.
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Reinhart E. Money as Medicine - Clinicism, Cash Transfers, and the Political-Economic Determinants of Health. N Engl J Med 2024; 390:1333-1338. [PMID: 38598803 DOI: 10.1056/nejmms2311216] [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: 04/12/2024]
Affiliation(s)
- Eric Reinhart
- From the Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago
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Dossett EC, Stuebe A, Dillion T, Tabb KM. Perinatal Mental Health: The Need For Broader Understanding And Policies That Meet The Challenges. Health Aff (Millwood) 2024; 43:462-469. [PMID: 38560796 DOI: 10.1377/hlthaff.2023.01455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Perinatal mental health is gaining recognition as a key antecedent of adverse maternal and child outcomes as the United States experiences a maternal mortality and morbidity crisis. Recent policy efforts have attempted to mitigate adverse outcomes through legislation such as the Taskforce Recommending Improvements for Unaddressed Mental Perinatal and Postpartum Health (TRIUMPH) for New Moms Act of 2021 and postpartum coverage through Medicaid expansion. Even with progress, perinatal mental health policy continues to grapple with a basic truth: The United States lacks an overarching health care system capable of meeting the mental health care needs of perinatal people and their families. Moreover, the burden of undiagnosed and untreated perinatal mental health challenges remains greatest among racially minoritized populations, such as Black, Asian, and multiracial people. A broader understanding of perinatal mental health is needed, grounded in the tenets of reproductive justice. From this perspective, we articulate specific policies to meet perinatal mental health challenges and promote thriving for birthing people and their families.
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Affiliation(s)
- Emily C Dossett
- Emily C. Dossett, University of Southern California, Los Angeles, California
| | - Alison Stuebe
- Alison Stuebe, University of North at Carolina Chapel Hill, Chapel Hill, North Carolina
| | | | - Karen M Tabb
- Karen M. Tabb , University of Illinois at Urbana-Champaign, Urbana, Illinois
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Leung CW, Odoms-Young A, Essel K. Food Insecurity Is a Source of Toxic Stress. JAMA Pediatr 2024; 178:327-328. [PMID: 38315497 DOI: 10.1001/jamapediatrics.2023.6400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
This Viewpoint discusses food insecurity as a source of toxic stress that can affect children’s health and advocates for developing research, clinical, and policy approaches to address the root causes of food insecurity.
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Affiliation(s)
- Cindy W Leung
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Kofi Essel
- George Washington University School of Medicine & Health Sciences, Washington, DC
- Elevance Health, Indianapolis, Indiana
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Jiménez-Solomon O, Irwin G, Melanie W, Christopher W. When money and mental health problems pile up: The reciprocal relationship between income and psychological distress. SSM Popul Health 2024; 25:101624. [PMID: 38380052 PMCID: PMC10876910 DOI: 10.1016/j.ssmph.2024.101624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
Background Longitudinal studies suggest that socioeconomic status (SES) and mental health have a bidirectional relationship such that SES declines lead to a deterioration of mental health (social causation), while worsening mental health leads to SES declines (social drift). However, the dynamic relationship between income and psychological distress has not been sufficiently studied. Methods We use cross-lagged panel models with unit fixed effects (FE-CLPM) and data from a five-wave representative panel (n = 3103) of working-age (18-64) New York City adults. Yearly measures include individual earnings, family income (income-to-needs), and psychological distress. We also examine effects by age, gender, education, and racial/ethnic identification. Results We find significant bidirectional effects between earnings and distress. Increases in past-year individual earnings decrease past-month psychological distress (social causation effect [SCE], standardized β= -0.07) and increases in psychological distress reduce next-year individual earnings (social drift effect [SDE], β= -0.03). Family income and distress only have a unidirectional relationship from past-year family income to distress (SCE, β= -.03). Strongest evidence of bidirectional effects between earnings and distress is for prime working-age individuals (SCE, β= -0.1; SDE, β= -0.03), those with less than bachelor's degrees (SCE, β= -0.08; SDE, β= -0.05), and Hispanics (SCE, β= -0.06; SDE, β= -0.08). We also find evidence of reciprocal effects between family income and distress for women (SCE, β= -0.03; SDE, β= -0.05), and Hispanics (SDE, β= -0.04; SDE, β= -0.08). Conclusions Individual earnings, which are labor market indicators, may be stronger social determinants of mental health than family income. However, important differences in social causation and social drift effects exist across groups by age, education, gender, and racial/ethnic identities. Future research should examine the types of policies that may buffer the mental health impact of negative income shocks and the declines in income associated with worsening mental health, especially among the most vulnerable.
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Affiliation(s)
- Oscar Jiménez-Solomon
- Center on Poverty and Social Policy, School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA
- New York State Center of Excellence for Cultural Competence, New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 69, New York, NY, 10032, USA
| | - Garfinkel Irwin
- Center on Poverty and Social Policy, School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA
| | - Wall Melanie
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 48, New York, NY, 10032, USA
- Department of Biostatistics, Mailman School of Public Health, Columbia University, 722 West 168th Street, R207, New York, NY, 10032, USA
| | - Wimer Christopher
- Center on Poverty and Social Policy, School of Social Work, Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA
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MCCONNELL MARGARET, AGARWAL SUMIT, HANSON ERIKA, MCCRADY ERIN, PARKER MARGARETG, BONA KIRA. Prescription for Cash? Cash Support to Low-Income Families in Maternal and Pediatric Health Care Settings. Milbank Q 2024; 102:64-82. [PMID: 37994263 PMCID: PMC10938935 DOI: 10.1111/1468-0009.12679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 11/24/2023] Open
Abstract
Policy Points Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health-related social needs, including screening and referral programs, may be insufficient because of persistent gaps, incomplete follow-up, administrative burden, and limited take-up. To bridge gaps in the social safety net, direct provision of cash transfers to low-income families experiencing health challenges during pregnancy, infancy, and early childhood could provide families with the flexibility and support to enable caregiving, increase access to health care, and improve health outcomes.
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Affiliation(s)
| | | | - ERIKA HANSON
- Center for Health Law and Policy Innovation, Harvard Law School
| | - ERIN MCCRADY
- Center for Health Law and Policy Innovation, Harvard Law School
| | - MARGARET G. PARKER
- Child Health Equity CenterUniversity of Massachusetts Chan Medical School
| | - KIRA BONA
- Harvard Medical School
- Dana‐Farber Cancer Institute
- Boston Children's Hospital
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Cozen AE, Carton T, Hamad R, Kornak J, Faulkner Modrow M, Peyser ND, Park S, Orozco JH, Brandner M, O'Brien EC, Djibo DA, McMahill-Walraven CN, Isasi CR, Beatty AL, Olgin JE, Marcus GM, Pletcher MJ. Factors associated with anxiety during the first two years of the COVID-19 pandemic in the United States: An analysis of the COVID-19 Citizen Science study. PLoS One 2024; 19:e0297922. [PMID: 38319951 PMCID: PMC10846720 DOI: 10.1371/journal.pone.0297922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/15/2024] [Indexed: 02/08/2024] Open
Abstract
COVID-19 increased the prevalence of clinically significant anxiety in the United States. To investigate contributing factors we analyzed anxiety, reported online via monthly Generalized Anxiety Disorders-7 (GAD-7) surveys between April 2020 and May 2022, in association with self-reported worry about the health effects of COVID-19, economic difficulty, personal COVID-19 experience, and subjective social status. 333,292 anxiety surveys from 50,172 participants (82% non-Hispanic white; 73% female; median age 55, IQR 42-66) showed high levels of anxiety, especially early in the pandemic. Anxiety scores showed strong independent associations with worry about the health effects of COVID-19 for oneself or family members (GAD-7 score +3.28 for highest vs. lowest category; 95% confidence interval: 3.24, 3.33; p<0.0001 for trend) and with difficulty paying for basic living expenses (+2.06; 1.97, 2.15, p<0.0001) in multivariable regression models after adjusting for demographic characteristics, COVID-19 case rates and death rates, and personal COVID-19 experience. High levels of COVID-19 health worry and economic stress were each more common among participants reporting lower subjective social status, and median anxiety scores for those experiencing both were in the range considered indicative of moderate to severe clinical anxiety disorders. In summary, health worry and economic difficulty both contributed to high rates of anxiety during the first two years of the COVID-19 pandemic in the US, especially in disadvantaged socioeconomic groups. Programs to address both health concerns and economic insecurity in vulnerable populations could help mitigate pandemic impacts on anxiety and mental health.
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Affiliation(s)
- Aaron E Cozen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Thomas Carton
- Louisiana Public Health Institute, New Orleans, LA, United States of America
| | - Rita Hamad
- Dept of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, United States of America
| | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Madelaine Faulkner Modrow
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Noah D Peyser
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Soo Park
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Jaime H Orozco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Matthew Brandner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
- Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States of America
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, NC, United States of America
| | | | | | - Carmen R Isasi
- Department of Epidemiology, Albert Einstein College of Medicine, The Bronx, NY, United States of America
| | - Alexis L Beatty
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Jeffrey E Olgin
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Gregory M Marcus
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
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15
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Nam J, Kwon SJ. Expansion of Child Tax Credits and Mental Health of Parents With Low Income in 2021. JAMA Netw Open 2024; 7:e2356419. [PMID: 38381435 PMCID: PMC10882416 DOI: 10.1001/jamanetworkopen.2023.56419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Importance The 2021 Child Tax Credit (CTC) expansion, as part of the American Rescue Plan Act, offered financial relief through generous monthly tax benefits to families with children amid the COVID-19 pandemic. In light of heightened concerns about mental health during the pandemic, the expanded CTC may have alleviated parental mental health challenges, especially within families with low income. Objective To investigate the association between the 2021 CTC expansion and mental health among parents with low income as measured by depression and anxiety symptoms. Design, Setting, and Participants This repeated cross-sectional study used data from the Household Pulse Survey covering April 14, 2021, to January 10, 2022, in the US. A difference-in-difference-in-differences estimator combined with propensity score matching was used to estimate the association of the expanded CTC with mental health symptoms among households with income less than $35 000. Exposure The monthly payment of expanded CTC from July 15 to December 15, 2021. Main Outcomes and Measures Parental mental health was measured by analyzing depression and anxiety symptoms using logistic regression. Results The weighted sample comprised 546 366 adults (mean [SD] age, 43.02 [14.54] years; 52.9% female). The most common education level was high school or less (36.0%), the highest frequency of household income distribution was $50 000 to $74 999 (16.1%), and the majority of the sample was employed (67.3%). The weighted mean (SD) number of children in the household was 0.92 (1.18). For the full sample, receiving expanded CTC benefits was associated with lower odds of experiencing anxiety symptoms (odds ratio, 0.730; 95% CI, 0.598-0.890). Subgroup analyses indicated that the positive associations of the policy with anxiety symptoms were particularly pronounced among the female, working-age (17-60 years), non-Hispanic White, and higher education groups. However, the policy expansion had no association with depression. Conclusions and Relevance These findings may provide valuable evidence for policy makers to consider when deliberating on the possibility of making the CTC expansion permanent or transforming it into a universal program.
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Affiliation(s)
- Jaehyun Nam
- Department of Social Welfare, Pusan National University, Busan, South Korea
| | - Sarah Jiyoon Kwon
- Crown Family School of Social Work, Policy and Practice, University of Chicago, Chicago, Illinois
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16
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Shafer PR. Does Supporting Children Help Their Parents Thrive? JAMA Netw Open 2024; 7:e2356376. [PMID: 38381436 DOI: 10.1001/jamanetworkopen.2023.56376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Affiliation(s)
- Paul R Shafer
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
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17
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Murray SL, Pascuzzi GS. Pursuing Safety in Social Connection: A Flexibly Fluid Perspective on Risk Regulation in Relationships. Annu Rev Psychol 2024; 75:379-404. [PMID: 37585668 DOI: 10.1146/annurev-psych-011123-024815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
People are fundamentally motivated to be included in social connections that feel safe, connections where they are consistently cared for and protected, not hurt or exploited. Romantic relationships have long played a crucial role in satisfying this fundamental need. This article reconceptualizes the risk-regulation model to argue that people draw on experiences from inside and outside their romantic relationships to satisfy their fundamental need to feel safe depending on others. We first review the direct relational cues (i.e., a partner's affectionate touch, responsive versus unresponsive behavior, and relative power) and indirect cues (i.e., bodily sensations, collective value in the eyes of others, and living conditions) that signal the current safety of social connection and motivate people to connect to others or protect themselves against them. We then review how people's chronic capacity to trust in others controls their sensitivity and reactivity to the safety cues. The article concludes with future research directions.
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Affiliation(s)
- Sandra L Murray
- Department of Psychology, The State University of New York at Buffalo, Buffalo, New York, USA; ,
| | - Gabriela S Pascuzzi
- Department of Psychology, The State University of New York at Buffalo, Buffalo, New York, USA; ,
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18
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Hankin BL, Griffith JM. What Do We Know About Depression Among Youth and How Can We Make Progress Toward Improved Understanding and Reducing Distress? A New Hope. Clin Child Fam Psychol Rev 2023; 26:919-942. [PMID: 37285011 PMCID: PMC10245370 DOI: 10.1007/s10567-023-00437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/08/2023]
Abstract
This paper summarizes many findings about depression among children and adolescents. Depression is prevalent, highly distressing, and exerts considerable burden worldwide. Rates surge from childhood through young adulthood and have increased over the last decade. Many risk factors have been identified, and evidence-based interventions exist targeting mostly individual-level changes via psychological or pharmacological means. At the same time, the field appears stuck and has not achieved considerable progress in advancing scientific understanding of depression's features or delivering interventions to meet the challenge of youth depression's high and growing prevalence. This paper adopts several positions to address these challenges and move the field forward. First, we emphasize reinvigoration of construct validation approaches that may better characterize youth depression's phenomenological features and inform more valid and reliable assessments that can enhance scientific understanding and improve interventions for youth depression. To this end, history and philosophical principles affecting depression's conceptualization and measurement are considered. Second, we suggest expanding the range and targets of treatments and prevention efforts beyond current practice guidelines for evidence-based interventions. This broader suite of interventions includes structural- and system-level change focused at community and societal levels (e.g., evidence-based economic anti-poverty interventions) and personalized interventions with sufficient evidence base. We propose that by focusing on the FORCE (Fundamentals, Openness, Relationships, Constructs, Evidence), youth depression research can provide new hope.
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Affiliation(s)
- Benjamin L Hankin
- Department of Psychology, University of Illinois Urbana Champaign, 603 E. Daniel Street, Champaign, IL, 61820, USA.
| | - Julianne M Griffith
- Department of Psychology, University of Illinois Urbana Champaign, 603 E. Daniel Street, Champaign, IL, 61820, USA
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19
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Cai J, Bidulescu A. Trends in unmet health care needs among adults in the U.S., 2019-2021. Prev Med 2023; 175:107699. [PMID: 37690672 DOI: 10.1016/j.ypmed.2023.107699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023]
Abstract
To examine recent trends in unmet health care needs among US adults, cross-sectional data of 93,047 adults from 2019 to 2021 National Health Interview Survey were analyzed. The weighted prevalence and changes in prevalence of cost-related or COVID-19-related unmet health care needs were estimated, first overall and then stratified by socio-demographic characteristics. The prevalence of cost-related unmet health care needs was 8.3% (95% CI: 7.8%, 8.8%) in 2019, which significantly decreased to 6.6% (95% CI: 6.2%, 7.0%) in 2020 and 6.1% (95% CI: 5.7%, 6.4%) in 2021. Across most socio-demographic groups, the prevalence of cost-related unmet health care needs significantly decreased between 2019 and 2020 (absolute changes ranged from -7.4% to -1%) and between 2019 and 2021 (absolute changes ranged from -10.5% to -1.2%), with significant reductions among uninsured adults, adults below the federal poverty level, and Hispanics. The prevalence of COVID-19-related unmet health care needs was 15.7% (95% CI: 14.9%, 16.4%) in 2020, which decreased to 11.9% (95% CI: 11.5%, 12.4%) in 2021. The prevalence of COVID-19-related unmet health care needs significantly decreased across most socio-demographic groups between 2020 and 2021 (absolute changes ranged from -4.9% to -2.4%), with significant reductions among the older, the unemployed, non-Hispanic Black adults, and adults with education level ≥ college. Overall, a modest decrease in the prevalence of both cost-related and COVID-19-related unmet health care needs was observed between 2019 and 2021. However, the fact that over 10% of US adults had unmet health care needs because of the COVID-19 pandemic is still concerning, warranting continued surveillance.
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Affiliation(s)
- Jiahui Cai
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, IN, United States.
| | - Aurelian Bidulescu
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, IN, United States
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20
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Chiang AY, Batra A, Hamad R. Promoting health equity through poverty alleviation policy: Factors associated with receipt of the 2021 U.S. Child Tax Credit in a nationwide sample. Prev Med 2023; 175:107717. [PMID: 37776907 DOI: 10.1016/j.ypmed.2023.107717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/22/2023] [Accepted: 09/27/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION The 2021 temporary expansion of the U.S. Child Tax Credit (CTC) was a potent policy that addressed poverty as a critical social determinant of health. Yet policies can only have their intended effects if they are implemented appropriately, and it is well known that not all who were eligible for the CTC received it. In this study, we investigated which individual- and state-level factors were correlated with receipt of the 2021 expanded CTC among eligible families. METHODS We used data from the U.S. Census Bureau Household Pulse Survey and included 76,994 CTC-eligible individuals. We used multivariable logistic regressions to evaluate individual- and state-level factors associated with self-reported CTC receipt during July-December 2021. RESULTS Roughly two-thirds of the CTC-eligible sample reported CTC receipt. CTC receipt was higher among eligible individuals who were female, aged 35-44 years (relative to younger individuals), Black, and married. Receipt was also higher among those with at least some college education, two or more children, and family income above $25,000, and among recipients of the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. For state-level factors, SNAP and Medicaid caseloads and the state earned income tax credit rate were associated with decreased receipt. CONCLUSION As Congress debates whether to make the CTC expansion permanent, this study provides timely evidence to inform poverty alleviation programs to increase participation among eligible and marginalized groups and achieve health equity.
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Affiliation(s)
- Amy Yunyu Chiang
- Department of Medicine, UCSF, San Francisco, CA, United States of America
| | - Akansha Batra
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, CA, United States of America
| | - Rita Hamad
- Department of Social & Behavioral Sciences, Harvard School of Public Health, Boston, MA, United States of America.
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21
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Cha E, Lee J, Tao S. Impact of the expanded child tax credit and its expiration on adult psychological well-being. Soc Sci Med 2023; 332:116101. [PMID: 37527567 DOI: 10.1016/j.socscimed.2023.116101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023]
Abstract
The COVID-19 pandemic has exacerbated stress and psychological distress among adults with children, with certain populations experiencing a greater mental health burden. The expanded Child Tax Credit (CTC) under the 2021 American Rescue Plan Act provided temporary relief to families with children through monthly payments from July through December 2021, offering a unique opportunity to examine the impact of a near-universal cash transfer on adult psychological well-being in the United States. We use the Household Pulse Survey Waves 28-41 (April 14, 2021 to January 10, 2022) to analyze the CTC expansion and Waves 34-42 (July 21, 2021 to February 7, 2022) to examine the expiration of the expanded CTC to investigate the effects of the expanded CTC and its expiration on psychological distress of adults in households with children and its differential effects by gender, education, marital status, and race and ethnicity (N = 167,772). We employ a difference-in-difference methodology by leveraging the policy-induced variation in the additional credits that households are eligible for. Our results indicate that the expanded CTC led to a significant reduction in the percentage of having at least mild symptoms of psychological distress in the overall sample, especially among female, single, married, and Hispanic adults. No significant effects were found on the rate of moderate or severe psychological distress symptoms, suggesting that more severe forms of psychological distress may require more comprehensive and long-term interventions. We find that more adults experienced moderate to severe psychological distress after the monthly CTC payments ended. We discuss the role of the expanded CTC in buffering mental health crises during the pandemic and the implications of the heterogeneous policy effects by subgroups.
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Affiliation(s)
- Eunho Cha
- Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA
| | - Jiwan Lee
- Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA
| | - Stacie Tao
- Columbia University, 1255 Amsterdam Avenue, New York, NY, 10027, USA.
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22
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Abstract
This Viewpoint describes how nondirected cash transfer programs influence the dynamics of child poverty, highlights pathways by which poverty reduction programs could improve child health, and provides suggested directions for future research and policy.
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Affiliation(s)
- Erin F. Flynn
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chén C. Kenyon
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditi Vasan
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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23
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Haeder SF, Moynihan DP. Most Americans support minimizing administrative burdens for Medicaid recipients as the public health emergency ends. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad001. [PMID: 38756841 PMCID: PMC10985919 DOI: 10.1093/haschl/qxad001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/03/2023] [Indexed: 05/18/2024]
Abstract
During the coronavirus disease 2019 (COVID-19) public health emergency (PHE), states were barred from disenrolling anyone from Medicaid unless the beneficiary asked to be disenrolled, moved out of state, or died. Coverage increased, but as the PHE ends an estimated 7 million eligible Americans are expected to lose insurance due to difficulty navigating the renewal process. The end of the PHE therefore offers state policymakers a chance to reassess the value of such administrative burdens as a variety of policy tools are available to mitigate these losses. We inform this discussion via a national survey that captures public preferences around administrative burdens in public health insurance. We find strong public support for burden-reduction techniques that minimize coverage losses such as using administrative data to shift burdens onto the state and better outreach and communication, with an average of 74% of respondents supporting each policy tool. This support holds across the ideological spectrum and demographic groups, but it is stronger among liberals than conservatives, for those with more direct experience of burdens, those who struggle with such burdens, and for those with lower racial prejudice.
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Affiliation(s)
- Simon F Haeder
- Department of Health Policy & Management, Texas A&M University, 1266 TAMU, 212 Adriance Lab Road, College Station, TX 77843, United States
| | - Donald P Moynihan
- McCourt School of Public Policy, Georgetown University, 37th Street NW O Street NW, Old North #100, Washington, DC 20057, United States
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24
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Mooney AC, Jackson KE, Hamad R, Fernald LCH, Hoskote M, Gosliner W. Experiences of distress and gaps in government safety net supports among parents of young children during the COVID-19 pandemic: a qualitative study. BMC Public Health 2023; 23:1099. [PMID: 37287030 DOI: 10.1186/s12889-023-16037-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/31/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic prompted rapid federal, state, and local government policymaking to buffer families from the health and economic harms of the pandemic. However, there has been little attention to families' perceptions of whether the pandemic safety net policy response was adequate, and what is needed to alleviate lasting effects on family well-being. This study examines the experiences and challenges of families with low incomes caring for young children during the pandemic. METHODS Semi-structured qualitative interviews conducted from August 2020 to January 2021 with 34 parents of young children in California were analyzed using thematic analysis. RESULTS We identified three key themes related to parents' experiences during the pandemic: (1) positive experiences with government support programs, (2) challenging experiences with government support programs, and (3) distress resulting from insufficient support for childcare disruptions. Participants reported that program expansions helped alleviate food insecurity, and those attending community colleges reported accessing a range of supports through supportive counselors. However, many reported gaps in support for childcare and distance learning, pre-existing housing instability, and parenting stressors. With insufficient supports, additional childcare and education workloads resulted in stress and exhaustion, guilt about competing demands, and stagnation of longer-term goals for economic and educational advancement. CONCLUSIONS Families of young children, already facing housing and economic insecurity prior to the pandemic, experienced parental burnout. To support family well-being, participants endorsed policies to remove housing barriers, and expand childcare options to mitigate job loss and competing demands on parents. Policy responses that either alleviate stressors or bolster supports have the potential to prevent distress catalyzed by future disasters or the more common destabilizing experiences of economic insecurity.
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Affiliation(s)
- Alyssa C Mooney
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 490 Illinois St, San Francisco, CA, 94158, USA.
| | - Kaitlyn E Jackson
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 490 Illinois St, San Francisco, CA, 94158, USA
| | - Rita Hamad
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 490 Illinois St, San Francisco, CA, 94158, USA
| | - Lia C H Fernald
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley, 2121 Berkeley Way, Room 5302, Berkeley, CA, 94720, USA
| | - Mekhala Hoskote
- University of California, Berkeley-University of California, San Francisco Joint Medical Program, 570 University Hall MC #7360, 2018 Oxford Street, Berkeley, CA, 94720, USA
| | - Wendi Gosliner
- Division of Agriculture and Natural Resources, Nutrition Policy Institute, University of California, 1111 Franklin Street, Oakland, CA, 94607, USA
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25
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Rook JM, Yama CL, Schickedanz AB, Feuerbach AM, Lee SL, Wisk LE. Changes in Self-Reported Adult Health and Household Food Security With the 2021 Expanded Child Tax Credit Monthly Payments. JAMA HEALTH FORUM 2023; 4:e231672. [PMID: 37354539 PMCID: PMC10290752 DOI: 10.1001/jamahealthforum.2023.1672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/21/2023] [Indexed: 06/26/2023] Open
Abstract
Importance The 2021 Expanded Child Tax Credit (ECTC) provided families with children monthly payments from July 2021 to December 2021. The association of this policy with adult health is understudied. Objective To examine changes in adult self-reported health and household food security before and during ECTC monthly payments. Design, Setting, and Participants This repeated cross-sectional study used multivariable regression with a difference-in-differences estimator to assess adult health and food security for 39 479 respondents to the National Health Interview Survey (January 2019 to December 2021) before vs during monthly payments. Analyses were stratified by income to focus on low-income vs middle-income and upper-income households. Exposure Eligibility for ECTC monthly payments from July 2021 to December 2021. Main Outcomes and Measures Overall self-reported adult health and household food security as binary outcomes (excellent or very good health vs good, fair, or poor health; food secure vs food insecure). Results In this nationally representative cross-sectional study of 39 479 US adults (mean [SD] age, 41.0 [13.0] years; 7234 [21.7%] Hispanic, 321 [0.9%] non-Hispanic American Indian/Alaska Native, 2205 [5.7%] non-Hispanic Asian, 5113 [13.7%] non-Hispanic Black, and 23 704 [55.8%] White individuals), respondents were predominantly female (21 511 [52.4%]), employed (33 035 [86.7%]), and married (19 838 [55.7%]). Before disbursement of ECTC monthly payments, 7633 ECTC-eligible adults (60.1%) reported excellent or very good health, and 10 950 (87.8%) reported having food security. Among ECTC-ineligible adults, 10 778 (54.9%) reported excellent or very good health and 17 839 (89.1%) reported food security. Following disbursement of monthly payments, ECTC-eligible adults experienced a 3.0 percentage point (pp) greater adjusted increase (95% CI, 0.2-5.7) in the probability of reporting excellent or very good health compared with ECTC-ineligible adults. Additionally, ECTC-eligible adults experienced a 1.9 pp greater adjusted increase (95% CI, 0.1-3.7) in the probability of food security than ECTC-ineligible adults. In income-stratified analyses, the association between ECTC eligibility and overall health was concentrated among middle-income and upper-income households (3.7-pp increase in excellent or very good health; 95% CI, 0.5-6.9). Conversely, the association between ECTC eligibility and food security was concentrated among low-income adults (3.9-pp increase in food security; 95% CI, 0-7.9). Conclusions and Relevance The results of this cross-sectional study suggest that monthly ECTC payments were associated with improved adult overall health and food security. Cash transfer programs may be effective tools in improving adult health and household nutrition.
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Affiliation(s)
- Jordan M. Rook
- Greater Los Angeles Veterans Administration Healthcare System, Los Angeles, California
- University of California, Los Angeles National Clinician Scholars Program, Los Angeles, California
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Cecile L. Yama
- University of California, Los Angeles National Clinician Scholars Program, Los Angeles, California
| | - Adam B. Schickedanz
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Alec M. Feuerbach
- Department of Emergency Medicine, State University of New York Downstate Kings County, New York
| | - Steven L. Lee
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lauren E. Wisk
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health at UCLA, Los Angeles, California
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26
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Kovski N, Pilkauskas NV, Michelmore K, Shaefer HL. Unconditional cash transfers and mental health symptoms among parents with low incomes: Evidence from the 2021 child tax credit. SSM Popul Health 2023; 22:101420. [PMID: 37151915 PMCID: PMC10148983 DOI: 10.1016/j.ssmph.2023.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/18/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023] Open
Abstract
The COVID-19 pandemic increased anxiety and depression in the U.S. population, particularly among low-income households, parents, and Black and Hispanic adults. To address the negative impacts of the pandemic, Congress temporarily expanded the Child Tax Credit (CTC) in 2021, providing a near-universal, unconditional cash transfer to families with children. Using a quasi-experimental, parameterized difference-in-differences research design, we examine the effects of the 2021 monthly CTC on symptoms of anxiety and depression in a large, national sample of parents with low incomes (N∼15,000). We study potential differences in the associations by race/ethnicity and consider whether CTC effects were stronger after a longer treatment period (for instance, due to greater dosage or delayed effects). We find some evidence that the monthly credit reduced parental anxiety and depression symptoms, although the results were not robust throughout all model specifications. Analyses stratified by race/ethnicity show stronger associations for non-Hispanic Black parents than for non-Hispanic White parents or Hispanic parents, although differences were small. We also find the credit reduced anxiety (but not depression) symptoms after three months of payments, suggesting that it took some time for the CTC to affect mental health symptoms. Overall, this study suggests that recurring cash transfers to families in poverty in the U.S. may have small beneficial effects on parental mental health.
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Affiliation(s)
- Nicole Kovski
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Natasha V Pilkauskas
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Katherine Michelmore
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - H Luke Shaefer
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
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