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Mechanism substitution in preventive innovations: Dissecting the reproduction of health inequalities in the United States. Soc Sci Med 2023; 337:116262. [PMID: 37898013 DOI: 10.1016/j.socscimed.2023.116262] [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: 03/18/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/30/2023]
Abstract
In the last three decades, numerous studies in different countries have corroborated the main postulates of the Fundamental Cause Theory (FCT), providing evidence showing how health inequalities are reproduced as society increases its capacity to control disease and/or avoid its consequences through preventive innovations. However, documenting the reproductive logic proposed by the theory requires the development of a dynamic analytical approach to consider socioeconomic disparities in the incorporation of multiple preventive innovations over time, which could act as mediating mechanisms of the durable relationship between socioeconomic status and health/mortality. This study draws on data from different waves of the National Health Interview Survey and the National Health and Nutrition Examination Survey to analyze the diffusion processes of various innovations in the U.S. The results of the study show that educational inequalities emerge, are amplified, and are reduced by the continuous diffusion of preventive innovations, supporting the meta-hypothesis of substitution of mediating mechanisms according to the interconnections of FCT and Diffusion of Innovation Theory.
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A review of mental health disparities during COVID-19: Evidence, mechanisms, and policy recommendations for promoting societal resilience. Dev Psychopathol 2023; 35:1821-1842. [PMID: 36097815 PMCID: PMC10008755 DOI: 10.1017/s0954579422000499] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five "pillars" of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.
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Social network, political climate, income inequality, and Americans uptake of monovalent COVID-19 booster. Vaccine 2023; 41:6077-6082. [PMID: 37652821 DOI: 10.1016/j.vaccine.2023.08.064] [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: 05/09/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
The COVID-19 pandemic has posed an unprecedented impact on Americans for over three years. To control the damage, a booster shot becomes increasingly necessary because the efficacy of the initial vaccine is waning and new variants of the virus are emerging. This study aims to understand factors at both individual and state levels that influence one's decision to take the monovalent booster. We merged data from a national survey administered in the Spring of 2022 with state-level indicators of the political climate, income inequality, and public health conditions. Multilevel logistic regression is adopted for statistical estimation. Findings show contrasting effects of the social network. More vaccinated people in one's network promote booster uptake, while more family members and close friends who contracted the virus in one's network inhibit booster uptake. In addition, residents of states with more votes for the Democratic candidate in the 2020 general election are more likely to take the booster. Meanwhile, residents from states with high income inequality are less likely to become boosted. This study identified multilevel determinants of the individual decision to receive the monovalent COVID-19 booster. The results imply the need to leverage the social network, weaken partisanship salience, and reduce income inequality to encourage booster uptake.
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Income and rural-urban status moderate the association between income inequality and life expectancy in US census tracts. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:24. [PMID: 36978201 PMCID: PMC10045499 DOI: 10.1186/s41043-023-00366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND A preponderance of evidence suggests that higher income inequality is associated with poorer population health, yet recent research suggests that this association may vary based on other social determinants, such as socioeconomic status (SES) and other geographic factors, such as rural-urban status. The objective of this empirical study was to assess the potential for SES and rural-urban status to moderate the association between income inequality and life expectancy (LE) at the census-tract level. METHODS Census-tract LE values for 2010-2015 were abstracted from the US Small-area Life Expectancy Estimates Project and linked by census tract to Gini index, a summary measure of income inequality, median household income, and population density for all US census tracts with non-zero populations (n = 66,857). Partial correlation and multivariable linear regression modeling was used to examine the association between Gini index and LE using stratification by median household income and interaction terms to assess statistical significance. RESULTS In the four lowest quintiles of income in the four most rural quintiles of census tracts, the associations between LE and Gini index were significant and negative (p between < 0.001 and 0.021). In contrast, the associations between LE and Gini index were significant and positive for the census tracts in the highest income quintiles, regardless of rural-urban status. CONCLUSION The magnitude and direction of the association between income inequality and population health depend upon area-level income and, to a lesser extent, on rural-urban status. The rationale behind these unexpected findings remains unclear. Further research is needed to understand the mechanisms driving these patterns.
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Income Inequality and Population Health: Examining the Role of Social Policy. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2023; 64:2-20. [PMID: 35848112 DOI: 10.1177/00221465221109202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Studies of the relationship between income inequality and life expectancy often speculate about the role of policy, but direct empirical research is limited. Drawing on the neo-materialist perspective, we examine whether the longitudinal association between income inequality and life expectancy is mediated and moderated by policy liberalism in U.S. states (2000-2014). More liberal policy contexts are characterized by greater efforts to regulate the economy, redistribute income, and protect vulnerable groups and lesser efforts to penalize deviant social behavior. We find that state-level income inequality is inversely associated with policy liberalism and life expectancy. The association between income inequality and life expectancy was not mediated by policy liberalism but was moderated by it. The association is attenuated in states with more liberal policy contexts, supporting the neo-materialist perspective. This finding illustrates how states like New York and California (with liberal policy contexts) can exhibit high income inequality and high life expectancy.
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Effect of wealth inequality on child and infant mortality in Togo. BMC Health Serv Res 2022; 22:1499. [PMID: 36482465 PMCID: PMC9733086 DOI: 10.1186/s12913-022-08912-4] [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: 09/16/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
At birth, individual has a health capital that depends on family, environmental and personal characteristics which depreciates over time requiring investment. It's in this sense that this article aims to analyze the effect of wealth inequality on infant and child mortality in Togo. This effect is accessed by a semi-parametric proportional hazard duration model of Cox. According to the model estimation which is based on data from the Multiple Indicator Cluster Survey (MICS) carried out in Togo in 2017, the results obtained show in one hand that coming from a less wealthy household increases the risk of death for children. On other hand, the results show that the possession of a source of drinking water, the possession of health insurance by the mother, and the mastery of the use of new information technologies and communication reduce the risk of infant and child mortality. In view of these results, policies to reduce wealth inequalities could help reduce the risk of infant and child mortality in proportions ranging from 0.075 to 0.264.
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The sources of the Kuznets relationship between the COVID-19 mortality rate and economic performance. INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION : IJDRR 2022; 81:103233. [PMID: 36093278 PMCID: PMC9444851 DOI: 10.1016/j.ijdrr.2022.103233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/11/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
This paper discusses the findings of an empirical analysis of the Kuznets, or reverse U-shaped relationship, between the COVID-19 mortality rate and economic performance. In the early stages of economic development, the COVID-19 mortality rate is anticipated to rise with rising economic activity and urbanization. Eventually, the mortality rate decreases at higher economic development levels as people and the government are more capable of investing in disease abatement measures. The quality of political institutions, wealth distribution, urbanization, vaccination rate, and improvements in healthcare systems are hypothesized to affect the COVID-19 mortality rate. Examining this relationship can be effective in understanding the change in the COVID-19 mortality rate at different economic performance stages and in identifying appropriate preventive measures. This study employed the negative binomial regression to model a cross-sectional dataset of 137 countries. Results indicated that the relationship between the per-head gross domestic product (GDP) level and the COVID-19 mortality rate appeared to follow a pattern like the Kuznets curve, implying that changes in institutional quality, healthcare advancements, wealth distribution, urbanization, vaccination rate, and the percentage of the elderly population were significant in explaining the relationship. Improvement of the healthcare system has a notable effect on lowering the COVID-19 mortality rate under more effective government conditions. Additionally, the results suggested that a higher per-head GDP is required to reverse the rising trend of the mortality rate under higher income inequality. Based on these results, preventive measures, and policies to reduce COVID-19 mortalities were recommended in the conclusion section.
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[Not Available]. Arch Psychiatr Nurs 2022; 40:A1-A2. [PMID: 36064254 DOI: 10.1016/j.apnu.2022.08.003] [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: 11/28/2022]
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Inequality begets inequality: Income inequality and socioeconomic achievement gradients across the United States. SOCIAL SCIENCE RESEARCH 2022; 107:102744. [PMID: 36058607 DOI: 10.1016/j.ssresearch.2022.102744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/06/2022] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
Social scientists have found income inequality is associated with an array of health and social problems, however the implications of income inequality for education are the subject of debate. Across 100 different areas (individual counties or collections of small counties) of the United States, we investigated how income inequality was associated with 1) average mathematics and reading achievement and 2) socioeconomic gradients in mathematics and reading achievement. Using data from the Kindergarten to Fifth Grade waves of the Early Childhood Longitudinal Study, Kindergarten Class of 2011 (ECLS-K 2011), we found areas of the United States with higher income inequality had lower average achievement in mathematics and a larger socioeconomic achievement gradient in reading. In further analyses, we investigated what characteristics of school and home environments mediated the relationship between income inequality and academic achievement. We found the association between income inequality and academic achievement was partly explained by the clustering of disadvantaged students in high poverty schools/districts and more intensive parenting practices among high SES parents (structured activity participation, educational expectations).
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Influences of Digital Transformation on Life Expectancy and the Gender Gap in European Countries. INTERNATIONAL JOURNAL OF ELECTRONIC GOVERNMENT RESEARCH 2022. [DOI: 10.4018/ijegr.298117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our paper empirically examines the influence of the digital transformation process on life expectancy employing a sample of 20 European countries over the period from 2015 to 2020. In the models, digitalization is captured by six measures. Our results illustrate that using the internet and online activities reduce life expectancy, whereas business digitization, e-commerce, digital public services, and higher digital skills in the population can improve the life expectancy of men and women, leading to a reduction in the gender gap. Furthermore, we detect that men are significantly more affected by the implementation of digital transformation, while online administrative procedures also lead to a rise in life expectancy but only in women. These effects only exist in the long term. We also find that digital connectivity, business digitization, e-commerce, and digital skills help people survive longer during the Covid-19 pandemic.
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Measuring economic, social and environmental wellbeing of Asian economies. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:18591-18604. [PMID: 34697708 DOI: 10.1007/s11356-021-16999-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/07/2021] [Indexed: 06/13/2023]
Abstract
This study aims to address the economic, social, and environmental wellbeing issues simultaneously by measuring the carbon intensity of wellbeing (CIWB) of Asian economies employing Prais-Winsten and pooled OLS estimator. The measure of CIWB is made taking into account a ratio of the two indicators-CO2 emissions per capita and life expectancy at birth. There is a paucity of studies that concentrate on human and social wellbeing indicators (i.e., water, sanitation, life expectancy) together applying the Environmental Kuznets Curve (EKC) hypothesis. Therefore, we have also investigated the EKC hypothesis as this theory hypothesizes the link involving human and environmental wellbeing and development. The findings utilizing the two econometric techniques indicate that in both the estimation models urban population access to an improved water source and total population access to improved water source has consistently negative and significant effects on CIWB. The fertility rate and prevalence of HIV pose no threat to CIWB. These findings demonstrate that social and human wellbeing indicators of the Asian economies are sustainable to this moment as they are lowering CIWB which is desirable. Contrary, GDP per capita, exports as a percent of GDP, and urban population have a significant and positive impact on CIWB which poses a challenge for the sustainability issue. We also have found the existence of the EKC hypothesis indicating environmental quality will increase past a turning point. The findings of the paper are well matched with the view of the "Economic and ecological modernization" theory and "human ecology" theory.
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Community-Level Vulnerabilities and Political Field Experiments. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1087203ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Although income inequality has become a focus of political and social discourse, counseling psychology research examining correlates and consequences of legitimizing income inequality remains sparse. A significant barrier to the study of income inequality is the lack of available measures to assess attitudes toward socioeconomic inequality. The purpose of this study was to develop and provide initial validity evidence for the Legitimizing Income Inequality Scale (LIIS). Results supported a bifactor structure for the LIIS with a general factor (ω = .95) and subfactors measuring Social Welfare Beliefs (ω = .92), Economic Fatalism (ω = .87), and Economic Meritocracy Beliefs (ω = .90). The LIIS significantly correlated in theoretically consistent directions with scores on measures of classist attitudes, socioeconomic conservatism, impression management, and colorblind racial attitudes. Implications for future research and training using the LIIS are provided.
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Racial and Ethnic Minority Pregnant Patients with Low-Income Experiences of Perinatal Care: A Scoping Review. Health Equity 2021; 5:554-568. [PMID: 34909522 PMCID: PMC8665802 DOI: 10.1089/heq.2021.0017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/12/2022] Open
Abstract
Purpose: The maternal mortality ratio for the United States (US) has consistently risen over recent decades. This mortality is especially pronounced within minority populations who experience a maternal mortality and morbidity rate that are much higher than their non-Hispanic white counterparts. Qualitative data are critical in gaining true insight from minority pregnant and postpartum persons. Such data should serve as the basis for building interventions and programs that seek to eradicate perinatal inequities. This review examines the qualitative literature on racial and ethnic minority pregnant patients with low income and their experiences during perinatal care (PNC) to identify recurrent themes that can be addressed through targeted interventions. Methods: PubMed, CINAHL, and Web of Science databases were searched for qualitative studies on racial and ethnic minority pregnant patients with low income and their experiences during PNC. Twenty-two articles were included for analysis. Thematic synthesis was performed to identify categories and recurring themes in each article. Results: Five major categories were identified as consistent experiences of pregnant patients with PNC clinicians: support, education, connection, communication, and trust. Of these, clinician support was the most consistently coded category. Eighteen of the 23 articles discussed tangible support patients had received from their clinicians, such as care coordination and referrals to support services. The second most coded category was education, which was represented in 16 articles. Education was mostly represented negatively as lack of adequate perinatal care education given during the perinatal period. Finally, the categories of connection, communication, and trust were represented by 18, 17, and 17 articles, respectively. Conclusions: These qualitative studies provided specific examples of what racial and ethnic minority pregnant patients with low income deemed positive and negative during the perinatal period and outline ways that these experiences can be improved. Future studies can take the experiences reported in this review to help inform interventions to improve patient experiences and health outcomes that minority persons face in the perinatal period.
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The impact of an unequal distribution of education on inequalities in life expectancy. SSM Popul Health 2021; 16:100954. [PMID: 34805476 PMCID: PMC8581344 DOI: 10.1016/j.ssmph.2021.100954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Prior research has found socio-economic determinants such as education to affect health outcomes. Yet, education is not distributed equally among the population. This article attempts to quantify the impact of unequal distribution of education on inequalities in life expectancy. We calculate a Gini coefficient of longevity from the life tables provided by the Human Mortality Database and a Gini coefficient of education using data on educational attainment from Barro and Lee (2013). We estimate linear regression models to examine the relationship between inequality in education and inequality in life expectancy at the country level for up to 31 European countries between 1970 and 2010. Results provide empirical evidence for a statistically significant positive association between educational inequality and inequalities of longevity. Confounding factors reflecting individual health behaviour such as cigarette or alcohol consumption do not exert a separate statistically significant effect on inequality in life expectancy. Findings are robust to alternative calculation of key variables, dropping a potential outlier, and an alternative estimation approach. These findings suggest that not only education, but also equality in education is a crucial factor for health outcomes. Continuing efforts should be directed towards the reduction of educational inequality in order to reduce inequality in longevity within a country.
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Prevalence of anxiety, depression, and stress among teachers during the COVID-19 pandemic: A PRISMA-compliant systematic review. Medicine (Baltimore) 2021; 100:e27684. [PMID: 34871251 PMCID: PMC8568426 DOI: 10.1097/md.0000000000027684] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Identifying the prevalence of anxiety, depression, and stress among teachers during the COVID-19 pandemic. METHODS Systematic review of original studies published in any language. Protocol published in PROSPERO under number CRD42021240543. The search was carried out in the Web of Science, PsycINFO, Pubmed, Embase, LILACS, and SciELO databases, using the descriptors: anxiety, depression, stress, teacher, faculty, COVID-19, and their synonyms. Narrative synthesis was carried out in line with the synthesis without meta-analysis in systematic reviews. RESULTS Of the 1372 records identified, 6 studies, all cross-sectional, were included in the review. The studies were carried out in China, Brazil, the United States of America, India, and Spain. Five studies included more women than men. The participants were aged from 24 to 60 years. Three studies included only school teachers, 2 included schools and universities teachers, and 1 only university teachers. Of the 5 studies, all dealt with remote activities and only 1 included teachers who returned to face-to-face classes 1 to 2 weeks ago. The prevalence of anxiety ranged from 10% to 49.4%, and depression from 15.9% to 28.9%, being considerably higher in studies with teachers who worked in schools. The prevalence of stress ranged from 12.6% to 50.6%. CONCLUSION The prevalence of anxiety, depression, and stress was high among teachers during the pandemic, with great variation between studies. Anxiety and stress were more prevalent in the Spanish study. The results show the need for measures for the care of teachers' mental health, especially when returning to face-to-face classes.
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Structural Intersectionality as a New Direction for Health Disparities Research. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2021; 62:350-370. [PMID: 34355603 PMCID: PMC8628816 DOI: 10.1177/00221465211032947] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This article advances the field by integrating insights from intersectionality perspectives with the emerging literatures on structural racism and structural sexism-which point to promising new ways to measure systems of inequality at a macro level-to introduce a structural intersectionality approach to population health. We demonstrate an application of structural intersectionality using administrative data representing macrolevel structural racism, structural sexism, and income inequality in U.S. states linked to individual data from the Behavioral Risk Factor Surveillance System to estimate multilevel models (N = 420,644 individuals nested in 76 state-years) investigating how intersecting dimensions of structural oppression shape health. Analyses show that these structural inequalities: (1) vary considerably across U.S. states, (2) intersect in numerous ways but do not strongly or positively covary, (3) individually and jointly shape health, and (4) are most consistently associated with poor health for black women. We conclude by outlining an agenda for future research on structural intersectionality and health.
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Spatial and temporal inequalities in mortality in the USA, 1968-2016. Health Place 2021; 70:102586. [PMID: 34010784 PMCID: PMC7613337 DOI: 10.1016/j.healthplace.2021.102586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 11/20/2022]
Abstract
Previous UK and European research has highlighted important variations in mortality between populations after adjustment for key determinants such as poverty and deprivation. The aim here was to establish whether similar populations could be identified in the US, and to examine changes over time. We employed Poisson regression models to compare county-level mortality with national rates between 1968 and 2016, adjusting for poverty, education, race (a proxy for exposure to racism), population change and deindustrialisation. Results are presented by means of population-weighted cartograms, and highlight widening spatial inequalities in mortality over time, including an urban to rural, and south-westward, shift in areas with the highest levels of such unexplained 'excess' mortality. There is a need to understand the causes of the excess in affected communities, given that it persists after adjustment for such a broad range of important health determinants.
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Trends of biomarkers of cardiovascular disease in the United States by income: Disparities between the richest 20% and the poorest 80%,1999-2018. SSM Popul Health 2021; 13:100745. [PMID: 33604447 PMCID: PMC7872963 DOI: 10.1016/j.ssmph.2021.100745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/03/2021] [Accepted: 01/26/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Income inequality between the richest 20% and the poorest 80% in the United States has been increasing over the past two decades. Emerging evidence indicates widening disparities between the two groups in cardiovascular disease prevalence as well. However, the mechanisms behind this trend remains unclear. This analysis examines whether a similar trend exists in the levels of biomarkers and risk factors of cardiovascular disease in the United States. METHODS We conducted a serial cross-sectional analysis of a nationally representative data from the National Health and Nutrition Examination Survey (NHANES) for participants age 20 or older between 1999 and 2018. We calculated trends in age-standardized means of body mass index (BMI), systolic blood pressure (SBP), and high-density lipoproteins (HDL) and the trend in prevalence of obesity, high SBP, and low HDL by income group. RESULTS This analysis included 49,764 participants. Age-standardized mean BMI increased every two years by an average of 0.15 kg/m 2 among the richest 20% and by an average of 0.21 kg/m 2 among the poorest 80%. Age-standardized mean SBP decreased every two years by an average of 0.13 mm Hg among the richest 20% and by an average of 0.10 mm Hg among the poorest 80%. Age-standardized mean HDL increased every two years by an average of 0.39 mg/dL among the richest 20% and by an average of 0.19 mg/dL among the poorest 80%. When adjusted for demographic factors and time, the richest 20% had lower mean BMI (OR = -0.67, 95% CI: -0.89, - 0.44), lower mean SBP (OR = -0.72, 95% CI: -1.24, -0.20), and higher mean HDL (OR = 3.04, 95% CI: 2.46, 3.62) compared to the poorest 80. CONCLUSION There are increasing disparities in cardiovascular disease biomarkers by income in the US. Between 1999 and 2018, improvement in biomarkers overwhelmingly occurred among the richest 20.
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Psychological impacts from COVID-19 among university students: Risk factors across seven states in the United States. PLoS One 2021; 16:e0245327. [PMID: 33411812 PMCID: PMC7790395 DOI: 10.1371/journal.pone.0245327] [Citation(s) in RCA: 287] [Impact Index Per Article: 95.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/28/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND University students are increasingly recognized as a vulnerable population, suffering from higher levels of anxiety, depression, substance abuse, and disordered eating compared to the general population. Therefore, when the nature of their educational experience radically changes-such as sheltering in place during the COVID-19 pandemic-the burden on the mental health of this vulnerable population is amplified. The objectives of this study are to 1) identify the array of psychological impacts COVID-19 has on students, 2) develop profiles to characterize students' anticipated levels of psychological impact during the pandemic, and 3) evaluate potential sociodemographic, lifestyle-related, and awareness of people infected with COVID-19 risk factors that could make students more likely to experience these impacts. METHODS Cross-sectional data were collected through web-based questionnaires from seven U.S. universities. Representative and convenience sampling was used to invite students to complete the questionnaires in mid-March to early-May 2020, when most coronavirus-related sheltering in place orders were in effect. We received 2,534 completed responses, of which 61% were from women, 79% from non-Hispanic Whites, and 20% from graduate students. RESULTS Exploratory factor analysis on close-ended responses resulted in two latent constructs, which we used to identify profiles of students with latent profile analysis, including high (45% of sample), moderate (40%), and low (14%) levels of psychological impact. Bivariate associations showed students who were women, were non-Hispanic Asian, in fair/poor health, of below-average relative family income, or who knew someone infected with COVID-19 experienced higher levels of psychological impact. Students who were non-Hispanic White, above-average social class, spent at least two hours outside, or less than eight hours on electronic screens were likely to experience lower levels of psychological impact. Multivariate modeling (mixed-effects logistic regression) showed that being a woman, having fair/poor general health status, being 18 to 24 years old, spending 8 or more hours on screens daily, and knowing someone infected predicted higher levels of psychological impact when risk factors were considered simultaneously. CONCLUSION Inadequate efforts to recognize and address college students' mental health challenges, especially during a pandemic, could have long-term consequences on their health and education.
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The multiplicative impacts of working hours and fine particulate matter concentration on life expectancy: A longitudinal analysis of US States. ENVIRONMENTAL RESEARCH 2020; 191:110117. [PMID: 32841634 DOI: 10.1016/j.envres.2020.110117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
This study contributes to interdisciplinary research on the social and environmental determinants of population health, with a focus on the interaction between working hours and fine particulate matter (PM2.5) concentration. The authors estimate longitudinal models of the relationship between US state-level average life expectancy and both average working hours and PM2.5 concentration for the 2005-2014 period. Results obtained from two-way fixed effects models indicate that average life expectancy is negatively associated with both average working hours and fine particulate matter concentration. Findings also indicate clear moderating relationships: the negative association between life expectancy and working hours is amplified as PM2.5 concentration increases, and the negative relationship between life expectancy and fine particulate matter concentration is amplified when average working hours increase. The results of this study underscore the need for additional research on the multiplicative impacts of socioeconomic factors and environmental factors in the modeling of population health.
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The Relative Importance of Globalization and Public Expenditure on Life Expectancy in Europe: An Approach Based on MARS Methodology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8614. [PMID: 33228227 PMCID: PMC7699569 DOI: 10.3390/ijerph17228614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND There has been a widespread debate about the overall impact of globalization on population, not just economically, but also in terms of health status. Moreover, the current health crisis is going to force governments to review the structure of the public budget to most effectively alleviate the negative economic and health effects on the population. OBJECTIVE The aim of this paper is to analyze the relative importance of globalization and the public budget composition-specifically the participation of public expenditure on healthcare, social services and environment in gross domestic product (GDP)-on life expectancy at birth in European countries during the period 1995-2017. METHODS The Multivariate Adaptive Regression Splines (MARS) methodology was applied to analyze the socioeconomic determinants of life expectancy at birth. RESULTS Our findings show that globalization has no relative importance as an explanatory variable of life expectancy in European countries, while government expenditure on social protection is the most relevant followed by public expenditure on health, gross national income per capita, education level of the population and public expenditure on environmental protection. CONCLUSION European strategies intended to impact on health outcome should spend more attention to the composition of public budget.
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With great inequality comes great responsibility: the role of government spending on population health in the presence of changing income distributions. Canadian Journal of Public Health 2020; 112:199-209. [PMID: 32959327 DOI: 10.17269/s41997-020-00407-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/19/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To determine the association between provincial government health and social spending and population health outcomes in Canada, separately for men and women, and account for the potential role of income inequality in modifying the association. METHODS We used data for nine Canadian provinces, 1981 to 2017. Health outcomes and demographic data are from Statistics Canada; provincial spending data are from provincial public accounts. We model the ratio of social-to-health spending ("the ratio") on potentially avoidable mortality (PAM), life expectancy (LE), potential years of life lost (PYLL), infant mortality, and low birth weight baby incidence. We interact the ratio with the Gini coefficient to allow for income inequality modification. RESULTS When the Gini coefficient is equal to its average (0.294), the ratio is associated with desirable health outcomes for adult men and women. For example, among women, a 1% increase in the ratio is associated with a 0.04% decrease in PAM, a 0.05% decrease in PYLL, and a 0.002% increase in LE. When the Gini coefficient is 0.02 higher than average, the relationship between the ratio and outcomes is twice as strong as when the Gini is at its average, other than for PAM for women. Infant-related outcomes do not have a statistically significant association with the ratio. CONCLUSION Overall, outcomes for men and women have similar associations with the ratio. Inequality increases the return to social spending, implying that those who benefit the most from social spending reap higher benefits during periods of higher inequality.
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What Is Driving the Drug Overdose Epidemic in the United States? JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2020; 61:275-289. [PMID: 32674692 DOI: 10.1177/0022146520939514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The demand-side perspective argues that the drug overdose epidemic is a consequence of changes in the economy that leave behind working-class people who lack a college education. In contrast, the supply-side perspective maintains that the epidemic is primarily due to changes in the licit and illicit drug environment, whereas a third, distinct perspective argues that income inequality is likely a key driver of the epidemic. To evaluate these competing perspectives, we use a two-level random intercept model and U.S. state-level data from 2006 to 2017. Contrary to the demand-side approach, we find that educational attainment is not associated with drug-related mortality. In support of the supply-side approach, we provide evidence indicating that opioid prescription rates are positively associated with drug-related mortality. We also find that income inequality is a key driver of the epidemic, particularly the lack of resources going to the bottom 20% of earners. We conclude by arguing that considerations of income inequality are an important way to link the arguments made by the demand-side and the supply-side perspectives.
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Confronting the Post-ACA American Health Crisis: Designing Health Care for Value and Equity. J Ambul Care Manage 2020; 42:202-210. [PMID: 31136391 DOI: 10.1097/jac.0000000000000278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The United States is in the midst of a health crisis marked by unprecedented 3-year declines in life expectancy. Addressing this national crisis requires alignment of public policies, public health policies, and health care policies, with the overarching aim of improving national health and health equity. Aligning national polices to support human needs provides a foundation for implementing post-Affordable Care Act national health care reform. Reform should start with the twin goals of improving health care value and equity. A focus on value, that is, outcomes and processes desired by patients, is critical to ensuring that resources are judiciously deployed to optimize individual and population health. A focus on health care equity ensures that the health care system is intentionally designed to minimize inequities in health care processes and outcomes, particularly for member of socially disadvantaged groups. All sectors related to the health care system-from policies and payment mechanisms to delivery design, measurement, patient engagement/democratization, training, and research-should be tightly aligned with improving health care value and equity during this next era of health care reform.
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How do perceived changes in inequality affect health? Health Place 2020; 62:102276. [DOI: 10.1016/j.healthplace.2019.102276] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 11/30/2022]
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Is there a relationship between welfare-state policies and suicide rates? Evidence from the U.S. states, 2000–2015. Soc Sci Med 2020; 246:112778. [DOI: 10.1016/j.socscimed.2019.112778] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 11/19/2022]
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Life Expectancy at Birth in Europe: An Econometric Approach Based on Random Forests Methodology. SUSTAINABILITY 2020. [DOI: 10.3390/su12010413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The objective of this work is to identify and classify the relative importance of several socioeconomic factors which explain life expectancy at birth in the European Union (EU) countries in the period 2008–2017, paying special attention to greenhouse gas emissions and public environmental expenditures. Methods: The Random Forests methodology was employed, which allows classification of the socioeconomic variables considered in the analysis according to their relative importance to explain health outcomes. Results: Per capita income, the educational level of the population, and the variable AREA (which reflects the subdivision of Europe into four relatively homogeneous areas), followed by the public expenditures on environmental and social protection, are the variables with the highest relevance in explaining life expectancy at birth in Europe over the perip.1 he peusto el correo e inciod 2008–2017. Conclusions: We have identified seven sectors as the main sources of greenhouse gas emissions: Electricity, gas, steam, and air conditioning supply; manufacturing; transportation and storage; agriculture, forestry, and fishing; construction; wholesale and retail trade, repair of motor vehicles and motorcycles; and mining and quarrying. Therefore, any public intervention related to environmental policy should be aimed at these economic sectors. Furthermore, it will be more effective to focus on public programs with higher relevance to the health status of the population, such as environmental and social protection expenditures.
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Income inequality and racial disparities in pregnancy-related mortality in the US. SSM Popul Health 2019; 9:100477. [PMID: 31517017 PMCID: PMC6734101 DOI: 10.1016/j.ssmph.2019.100477] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/24/2019] [Accepted: 08/25/2019] [Indexed: 12/24/2022] Open
Abstract
In this ecological study, we examined the associations between state-level income inequality and pregnancy-related mortality among non-Hispanic (NH) black and NH white populations across the US. We estimated total population and race-specific 5-year pregnancy-related mortality ratios in each state based on national death and live birth records from 2011 to 2015. We obtained data on Gini coefficients for income inequality and population-level characteristics from the US Census American Community Survey. Poisson regression with robust standard errors estimated pregnancy-related mortality rate ratios (RR) and 95% confidence intervals (CI) associated with a one unit increase in income inequality overall and separately within black and white populations. Adjusted linear regression models estimated the associations between income inequality and magnitude of the absolute and relative racial inequity in pregnancy-related mortality within states. Across all states, increasing contemporaneous income inequality was associated with a 15% and 5-year lagged inequality with 14% increase in pregnancy-related mortality among black women (aRR = 1.15, 95% CI = 1.05; 1.25 and aRR = 1.14, 95% CI = 1.04; 1.24, respectively) after controlling for states' racial compositions and socio-economic conditions. In addition, both lagged and contemporaneous income inequality were associated with larger absolute and relative racial inequities in pregnancy-related mortality. These findings highlight the role of contextual factors in contributing to pregnancy-related mortality among black women and the persistent racial inequity in maternal death in the US.
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Trends in inequality in life expectancy at birth between 2004 and 2017 and projections for 2030 in Korea: multiyear cross-sectional differences by income from national health insurance data. BMJ Open 2019; 9:e030683. [PMID: 31272989 PMCID: PMC6615846 DOI: 10.1136/bmjopen-2019-030683] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The current status, time trends and future projections of a national health equity target are crucial elements of national health equity surveillance. This study examined time trends in inequality by income in life expectancy (LE) at birth between 2004 and 2017 and made future projections for the year 2030 in Korea. DESIGN Using individually linked mortality data, time trends in inequality by income in LE at birth were examined. The LE projection was made with the Lee-Carter model. SETTING Total Korean population and death data derived from the National Health Information Database of the National Health Insurance Service. PARTICIPANTS A total of 685 773 157 subjects and 3 486 893 deaths between 2004 and 2017 were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES Annual LE and the magnitude of inequality by income in LE between 2004 and 2030. RESULTS Inequality by income in LE among the total Korean population increased during the past 14 years, and this inequality is projected to become even greater in the future. In 2030, the magnitude of inequality by income in LE is projected to increase by 0.25 years in comparison to the magnitude in 2017. The increase in LE inequality was projected to be more prominent among women, with a projected 1.08 year increase in LE inequality between 2017 and 2030. CONCLUSION Aggressive policies should be developed to close the increasing LE gap in Korea. LE inequalities by income should be considered as a measurable target for health equity in the process of establishing the National Health Plan 2030 in Korea.
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A Causal Analysis of Life Expectancy at Birth. Evidence from Spain. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2367. [PMID: 31277340 PMCID: PMC6650812 DOI: 10.3390/ijerph16132367] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 06/26/2019] [Accepted: 06/30/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND From a causal point of view, there exists a set of socioeconomic indicators concerning life expectancy. The objective of this paper is to determine the indicators which exhibit a relation of causality with life expectancy at birth. METHODS Our analysis applies the Granger causality test, more specifically its version by Dumitrescu-Hurlin, starting from the information concerning life expectancy at birth and a set of socioeconomic variables corresponding to 17 Spanish regions, throughout the period 2006-2016. To do this, we used the panel data involving the information provided by the Spanish Ministry of Health, Consumer Affairs and Social Welfare (MHCSW) and the National Institute of Statistics (NIS). RESULTS Per capita income, and the rate of hospital beds, medical staff and nurses Granger-cause the variable "life expectancy at birth", according to the Granger causality test applied to panel data (Dumitrescu-Hurlin's version). CONCLUSIONS Life expectancy at birth has become one of the main indicators able to measure the performance of a country's health system. This analysis facilitates the identification of those factors which exhibit a unidirectional Granger-causality relationship with life expectancy at birth. Therefore, this paper provides useful information for the management of public health resources from the point of view of the maximization of social benefits.
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No generalizable effect of income inequality on public support for governmental redistribution among rich democracies 1987-2010. SOCIAL SCIENCE RESEARCH 2019; 81:170-191. [PMID: 31130195 DOI: 10.1016/j.ssresearch.2019.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 06/09/2023]
Abstract
We revisit a longstanding hypothesis that the public become more supportive of redistributive policy as income inequality rises. Previous tests of this hypothesis using various forms of general least squares regressions are inconclusive. We suggest improvements and alternatives to these tests. Using the World Inequality Data and International Social Survey Program we analyze 91 surveys in 18 countries. We incorporate three alternative measures of income inequality, including a measure of liberalization as a known cause of increases in income inequality. We also employ two alternative test formats that arguably reflect the data generating model better than a least squares regression. The first is vector-autoregression aiming to account for path dependency of public opinion and income inequality, and the endogeneity between them. Next is qualitative comparative analysis to capture sets of conditions that collectively should have led to inequality having an impact on public opinion. Finally, we run our regression models separately for low and high socio-economic strata. In all tests we find no measurable impact of income inequality on support for redistribution. From a macro-perspective we argue that this suggests ruling out a general effect that exists across space and time, and focusing instead on theory to explain why there should not be a general effect. Some arguments suggest the public are normatively opposed to what sounds like 'handouts'. We therefore discuss model specification via theory, but also Type II errors, statistical power and the limitations of our conclusions.
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State inequality, socioeconomic position and subjective cognitive decline in the United States. SSM Popul Health 2019; 7:100357. [PMID: 30886886 PMCID: PMC6402371 DOI: 10.1016/j.ssmph.2019.100357] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/13/2019] [Accepted: 01/16/2019] [Indexed: 01/08/2023] Open
Abstract
Background Social gradients in health have been observed for many health conditions and are suggested to operate through the effects of status anxiety. However, the gradient between education and Alzheimer’s disease is presumed to operate through cognitive stimulation. We examined the possible role of status anxiety through testing for state-level income inequality and social gradients in markers of socioeconomic position (SEP) for Alzheimer’s disease risk. Methods Using data from the cross-sectional 2015 and 2016 Behavioral Risk Factor Surveillance System (BRFSS) and the U.S. Census Bureau’s American Community Survey, we tested for the association between U.S. state-level income inequality and individual SEP on subjective cognitive decline (SCD) – a marker of dementia risk – using a generalized estimating equation and clustering by state. Results State income inequality was not significantly associated with SCD in our multivariable model (OR 1.2; 95% CI: 0.9, 1.6; p=0.49). We observed a clear linear relationship between household income and SCD where those with an annual household income of 50k to 75k had 1.4 (95% CI: 1.3, 1.6) times the odds and those with household incomes of less than $10,000 had 4.7 (95% CI: 3.8, 5.7) times the odds of SCD compared to those with household income of more than $75,000. We also found that college graduates (ref.) and those who completed high school (OR: 1.1; 95% CI 1.04, 1.2) fared better than those with some college (OR: 1.3, 95% CI 1.2, 1.4) or less than a high school degree (OR: 1.5; 95% CI: 1.4, 1.7). Conclusions Income inequality does not play a dominant role in SCD, though a social gradient in individual income for SCD suggests the relationship may operate in part via status anxiety. Research suggests education impacts cognitive decline via cognitive stimulation Associations with income and inequality may suggest a “status anxiety” mechanism Income inequality was not statistically associated with cognitive decline We found a dose-response effect of individual income on cognitive decline Status anxiety may contribute to disparities in dementia risk
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Air quality and life expectancy in the United States: An analysis of the moderating effect of income inequality. SSM Popul Health 2018; 7:100346. [PMID: 30627626 PMCID: PMC6321951 DOI: 10.1016/j.ssmph.2018.100346] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/22/2018] [Accepted: 12/26/2018] [Indexed: 11/28/2022] Open
Abstract
Although studies have shown that air pollution can be devastating to population health, little is known about the health implications of the intersection of air pollution and income inequality. We investigate if air pollution is especially detrimental to the health of US state populations characterized by more inequitable distributions of income. In other words, are the populations of states with higher levels of income inequality especially vulnerable to similar levels of air pollution? We use two-way fixed-effects panel regression techniques to analyze longitudinal data for 49 US states and the District of Columbia (2000-2010) to model state-level life expectancy as a function of fine particulate matter, income inequality, and other state-level factors. We estimate models with interaction terms to formally assess whether the association between fine particulate matter and life expectancy varies by level of state income inequality. Across multiple life expectancy outcomes and additive models, states with higher PM2.5 levels tend to exhibit lower average life expectancy. This general pattern is observed with our specifications for raw and weighted PM2.5 and with adjustments for income share of the top 10%, total population, GDP per capita, median household income, median age, percent college degree or higher, percent black, and percent Hispanic/Latino. We also find that the association between state PM2.5 levels and average life expectancy intensifies in states with higher levels of income inequality. More specifically, PM2.5 levels are more detrimental to population life expectancy in states where a higher percentage of income is concentrated in the top 10% of the state income distribution. We discuss the implications of our results for future research in social epidemiology and environmental justice.
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Abstract
Purpose: Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set. Methods: Adults residents of Ohio responding to the 2015 Ohio Medicaid Assessment Survey were included in the analysis. Ohio's 88 counties were classified into quartiles according to the Gini coefficient of income inequality. The primary outcome was a composite of self-reported unmet dental care, vision care, mental healthcare, prescription medication, or other healthcare needs within the past year. Unmet healthcare needs were compared according to county inequality quartile using weighted logistic regression. Results: The analytic sample included 37,140 adults. The weighted proportion of adults with unmet healthcare needs was 28%. In multivariable logistic regression, residents of counties in the highest (odds ratio [OR]=1.13, 95% confidence interval [CI]: 1.01-1.26; p=0.030) and second-highest (OR=1.16, 95% CI: 1.04-1.30; p=0.010) quartiles of income inequality experienced more unmet healthcare needs than residents of the most equal counties. Conclusion: Higher county-level income inequality was associated with individual unmet healthcare needs in a large state survey. This finding represents novel evidence for an individual-level association that may explain aggregate-level associations between community economic inequality and population health outcomes.
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