Ethnoracial Disparities in Self-Rated Health: Exploring the Impact of Skin Color and Other Ethnoracial Characteristics in Mexico

OBJECTIVES

This manuscript aims to understand the association between self-rated health and ethnic-racial characteristics (i.e., skin color, self-ascription, and Indigenous language) in the context of the Mexican population.

DESIGN

Logistic regression analyses, using the 2019 PRODER (N = 7187)-a representative survey at the national level. We centered the analysis on two measures of skin color: the interviewer assessment of color skin (that has been used in previous studies), and the ITA scale, a measure constructed from optical digital colorimeter readings (a novel method in ethnoraciality studies in Mexico, included in the PRODER survey).

RESULTS

In comparison to the interviewer's assessment of skin color, the ITA score shows a significant association with self-rated health, even in the presence of individual conditions, sociodemographic traits, and life-course events. In contrast, ethnic-racial self-ascriptions and speaking of an Indigenous language do not show any statistical associations.

CONCLUSION

Contrary to previous research, our results suggest a positive association between skin color and self-rated health, when the former is assessed with the colorimeter readings; it means that those with lighter color skin are more prone to report a better health perception. It has methodological implications in the way skin color is observed.

Food insecurity and mental health among US adults during the COVID-19 pandemic: Results from National Health Interview Survey, 2020-2021

OBJECTIVE

To examine socio-demographic disparities in food insecurity during the COVID-19 pandemic and the association between food insecurity and mental health among US adults overall and communities vulnerable to food insecurity.

METHODS

A cross-sectional study was conducted using the 2020-2021 National Health Interview Survey of 57,456 US adults. Weighted multivariable logistic regression models were used to estimate the association between food insecurity and anxiety or depression symptoms in overall US adults and subgroups including young adults (18-34 years), females, Hispanic people, non-Hispanic Black people, individuals with prior COVID-19 infection, the unemployed, low-income participants, participants with children, and Supplemental Nutrition Assistance Program (SNAP) participants.

RESULTS

Young or middle age, female sex, Hispanic/non-Hispanic Black/other race/ethnicity, lower education level, unmarried/other marital status, unemployment, being below the federal poverty level, and greater number of persons in the household were associated with food insecurity (AOR ranged from 1.35 to 2.70, all p < 0.05). Food insecurity was independently associated with anxiety (AOR = 2.67, 99 % CI: 2.33, 3.06) or depression (AOR = 3.04, 99 % CI: 2.60, 3.55) symptoms in the overall adults. Significant associations between food insecurity and anxiety or depression symptoms were also observed in all subgroups (AOR ranged from 1.95 to 3.28, all p < 0.0001). Compared with overall adults, the magnitude of the association was greater for participants with children, females (for depression only), and non-Hispanic Black people (for depression only).

LIMITATIONS

The cross-sectional design prevents inference of causality.

CONCLUSIONS

Comprehensive policies are needed to ensure accessible and affordable food resources to reduce disparities in food insecurity and improve mental health, especially for those socioeconomically disadvantaged communities.

Socioeconomic factors associated with use of telehealth services in outpatient care settings during the COVID-19

BACKGROUND

To examine potential changes and socioeconomic disparities in utilization of telemedicine in non-urgent outpatient care in Nevada since the COVID-19 pandemic.

METHODS

This retrospective cross-sectional analysis of telemedicine used the first nine months of 2019 and 2020 electronic health record data from regular non-urgent outpatient care in a large healthcare provider in Nevada. The dependent variables were the use of telemedicine among all outpatient visits and using telemedicine more than once among those patients who did use telemedicine. The independent variables were race/ethnicity, insurance status, and language preference.

RESULTS

Telemedicine services increased from virtually zero (16 visits out of 237,997 visits) in 2019 to 10.8% (24,159 visits out of 222,750 visits) in 2020. Asians (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.85,0.94) and Latinos/Hispanics (OR = 0.89; 95% CI = 0.85, 0.94) were less likely to use telehealth; Spanish-speaking patients (OR = 0.68; 95% CI = 0.63, 0.73) and other non-English-speaking patients (OR = 0.93; 95% CI = 0.88, 0.97) were less likely to use telehealth; and both Medicare (OR = 0.94; 95% CI = 0.89, 0.99) and Medicaid patients (OR = 0.91; 95% CI = 0.87, 0.97) were less likely to use telehealth than their privately insured counterparts. Patients treated in pediatric (OR = 0.76; 95% CI = 0.60, 0.96) and specialty care (OR = 0.67; 95% CI = 0.65, 0.70) were less likely to use telemedicine as compared with patients who were treated in adult medicine.

CONCLUSIONS

Racial/ethnic and linguistic factors were significantly associated with the utilization of telemedicine in non-urgent outpatient care during COVID-19, with a dramatic increase in telemedicine utilization during the onset of the pandemic. Reducing barriers related to socioeconomic factors can be improved via policy and program interventions.

Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement

INTRODUCTION

Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation.

METHODS

A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes.

RESULTS

The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US.

CONCLUSION

Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.

Socioeconomic Disparities Associated with Access to Oculofacial Plastic Surgeons: A Cross-Sectional Analysis of US County Demographics

PURPOSE

To compare population demographics with the geographic distribution of oculofacial plastic surgeons (OPSs) in the United States.

DESIGN

A cross-sectional study design was used to investigate demographic differences between counties with 1 or more OPSs and counties with zero OPSs.

PARTICIPANTS

The number of OPSs were identified in each US county using online public databases: American Society of Ophthalmic Plastic and Reconstructive Surgeons and American Academy of Ophthalmology. Counties were categorized into 2 groups: 1 or more OPSs and zero OPSs. Demographic characteristics at the county level were obtained from the 2021 US Census Bureau Population Estimates and the American Community Survey. Cost of living was collected from the 2022 Economic Policy Institute Family Budget Calculator.

MAIN OUTCOME MEASURES

Socioeconomic demographics of the US population as related to geographic OPS distribution.

RESULTS

A total of 1238 OPSs were identified. States with the most OPSs per million were Hawaii (6.2), D.C. (6.0), Connecticut (5.8), Utah (5.1), and Maryland (5.0). Among 3143 counties, 2725 (86.7%) had zero OPSs and 418 (13.3%) had 1 or more OPSs. Counties with 1 or more OPSs had a higher median (standard deviation) household income versus counties with zero OPSs ($72 471 [$19 152] vs. $56 152 [$13 675]; difference $16 319; 95% confidence interval [CI], $14 300-$18 338; P < 0.001). The annual cost of living per person (standard deviation) was higher in counties with 1 or more OPSs versus counties with zero OPSs ($39 238 [$6992] vs. $36 227 [$3516]; difference $3011; 95% CI, $2328-$3694; P < 0.001). Counties with zero OPSs versus counties with 1 or more OPSs had higher proportions of persons with only Medicaid (15.6% vs. 13.6%; difference 2.0%; 95% CI, 1.4%-2.5%; P < 0.001), no health insurance (9.9% vs. 8.0%; difference 1.9%; 95% CI, 1.5%-2.4%; P < 0.001), no household internet access (17.2% vs. 9.6%; difference 7.6%; 95% CI, 7.1%-8.0%; P < 0.001), and higher proportions of persons aged 65 years or older (20.0% vs. 17.0%; difference 3.0%; 95% CI, 2.5%-3.5%; P < 0.001).

CONCLUSIONS

This cross-sectional analysis of all US counties revealed socioeconomic disparities associated with access to OPSs.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Associations between dietary behaviours and the mental and physical well-being of Swedish adolescents

AIMS

This study aims to investigate the association between dietary behaviours, overweight/obesity, and mental health and well-being among Swedish adolescents.

METHODS

Data from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey of 3692 adolescents aged ≈11, ≈13, and ≈15 years was analysed. We evaluated the prevalence and association of dietary behaviours, characterised by daily intake of fruits and vegetables, consumption of sugar-sweetened beverages (SSBs) and sweets once per week, and daily consumption of family meals and breakfast, with socioeconomic and demographic factors. Multivariate logistic regression models (adjusted and unadjusted) were then used to examine the relationship between dietary behaviours, overweight/obesity, and mental health and well-being including psychosomatic complaints, life satisfaction, and school-related pressure.

RESULTS

Boys were more likely to eat breakfast and have meals together with their family than girls, but their fruit and vegetable intake was lower compared to girls. Adolescents with lower socioeconomic status (low family affluence, families perceived 'not well-off' and two unemployed parents), single-parent households and twoforeign born parents were more likely to engage in poorer dietary behaviours. Daily breakfast, family meals, fruit and vegetable intake were positively associated with mental health and well-being. Specifically, daily family meals were linked to higher life satisfaction, fewer psychosomatic complaints, and reduced school-related pressure. Breakfast emerged as a beneficial dietary habit, associated with higher life satisfaction, and a lower likelihood of psychosomatic complaints, school-related pressure, and overweight/obesity. Fruit and vegetable consumption was consistently associated with better mental health and well-being while associations between SSBs and sweets were mixed.

CONCLUSIONS

Improving mental health and well-being, along with tackling the rising rates of mental illness and challenges related to overweight/obesity in adolescents constitute key public health priorities. Implementing policies that promote the intake of fruits and vegetables, reducing the consumption of SSBs and sweets, and emphasizing the value of having breakfast and sharing family meals could offer a cost-effective public health intervention.

The Role of County-Level Persistent Poverty in Stroke Mortality in the USA

Stroke is a major health concern in the USA, disproportionately affecting socioeconomically disadvantaged groups. This study investigates the link between persistent poverty and stroke mortality rates in residents aged 65 and above, positing that sustained economic challenges at the county level correlate with an increase in stroke-related deaths. Persistent poverty refers to a long-term state where a significant portion of a population lives below the poverty threshold for an extended period, typically measured over several decades. It captures the chronic nature of economic hardship faced by a community across multiple generations. Utilizing data from the CDC Wonder database and the American Community Survey, we conducted a comprehensive analysis across US counties, differentiating them by persistent poverty status. Our results indicate a statistically significant link between persistent poverty and increased mortality from ischemic and hemorrhagic strokes; counties afflicted by long-standing poverty were associated with an additional 33.49 ischemic and 8.16 hemorrhagic stroke deaths per 100,000 residents annually compared to their wealthier counterparts. These disparities persisted when controlling for known stroke risk factors and other socioeconomic variables. These results highlight the need for targeted public health strategies and interventions to address the disparities in stroke mortality rates and the broader implications for healthcare equity. The study underscores the vital role of socioeconomic context in health outcomes and the urgency of addressing long-term poverty as a key determinant of public health.

Socioeconomic disparities and health literacy: Unraveling the impact on diagnostic and cancer care in Uruguay

BACKGROUND

Disparities in the timely diagnosis and care of cancer patients, particularly concerning geographical, racial/ethnic, and economic factors, remain a global health challenge. This study explores the multifaceted interplay between socioeconomic status, health literacy, and specific patient perceptions regarding care access and treatment options that impact cancer care in Uruguay.

METHODS

Using the Cancer Health Literacy Test, Spanish Version (CHLT-30-DKspa), and a highly comprehensive questionnaire, we dissected the factors influencing the pathway to diagnosis and route of cancer care. This was done to identify delays by analyzing diverse socioeconomic and sex subgroups across multiple healthcare settings.

RESULTS

Patients with lower income took longer to get an appointment after showing symptoms (p = 0.02) and longer to get a diagnosis after having an appointment (p = 0.037). Race/ethnicity also had a significant impact on the length of time from symptoms to first appointment (p =0.019), whereas employment status had a significant impact on patients being susceptible to diagnostic delays beyond the advocated 14-day window (p = 0.02). Higher educational levels were positively associated with increased cancer health literacy scores (p = 0.043), revealing the potential to mitigate delays through health literacy-boosting initiatives. Women had significantly higher self-reported symptom duration before seeking an intervention (p = 0.022). We also found many other significant factors effecting treatment delays and cancer health literacy.

CONCLUSIONS

While affirming the global pertinence of socioeconomic- and literacy-focused interventions in enhancing cancer care, the findings underscore a complex, gendered, and perceptually influenced healthcare navigation journey. The results highlight the urgent necessity for strategically crafted, globally relevant interventions that transcend equitable access to integrate literacy, gender sensitivity, and patient-perception alignments in pursuit of optimized global cancer care outcomes.

Rates of Hirschsprung-Associated Enterocolitis Decrease With Increasing Child Opportunity Index

BACKGROUND

Hirschsprung-associated enterocolitis (HAEC) is the most common cause of morbidity and mortality in patients with Hirschsprung disease (HD). There is a correlation between social determinants of health (SDOH) and outcomes in children with HD. The Child Opportunity Index (COI) is a publicly available dataset that stratifies patients by address into levels of opportunity. We aimed to understand if a relationship exists between COI and HAEC.

METHODS

A single-institution, IRB-approved, retrospective cohort study was performed of children with HD. Census tract information was used to obtain COI scores, which were stratified into categories (very low, low, medium, high, very high). Subgroups with and without history of HAEC were compared.

RESULTS

The cohort had 100 patients, of which 93 had a COI score. There were 27 patients (29.0%) with HAEC. There were no differences in demographics or clinical factors, including length of aganglionic colon, operative approach, and age at pull-through. As child opportunity score increased from very low to very high, there was a statistically significant decrease in the incidence of HAEC (p = 0.04).

CONCLUSION

We demonstrate a significant association between increasing opportunity and decreasing incidence of HAEC. This suggests an opportunity for targeted intervention in populations with low opportunity.

LEVEL OF EVIDENCE

III.

IRB NUMBER

IRB14-00232.

Sociodemographic Disparities in Preoperative Visual Acuity and Cataract Surgery Utilization in the San Francisco Bay Area

OBJECTIVE

We examined whether cataract surgery utilization and preoperative visual acuity were associated with patient-specific factors, including ocular findings and comorbidities, general biomedical factors, and/or sociodemographic factors.

DESIGN

Retrospective, cross-sectional study.

SUBJECTS, PARTICIPANTS, AND/OR CONTROLS

We reviewed the electronic health records of patients from 2012 to 2022 who were examined and followed for at least 2 years by an eye care provider at University of California San Francisco Health (UCSF Health) and who had cataract in at least one eye associated with best-corrected visual acuity of 20/25 or worse. Data include ocular factors (e.g., best-corrected visual acuity, lens opacity grade, diagnoses of glaucoma, and/or age-related macular degeneration), biomedical comorbidities, and sociodemographic factors including race/ethnicity, health insurance coverage, primary language spoken, and social vulnerability index.

METHODS

Logistic and multivariate regression analyses.

MAIN OUTCOME MEASURES

We examined cataract surgery utilization and preoperative best-corrected visual acuity.

RESULTS

Compared to White and Asian patients, Black patients had the lowest rates of cataract surgery utilization and the poorest mean preoperative visual acuities, with Hispanic patients following in second place in both categories. However, when the analysis controlled for sociodemographic and biomedical factors, Medicaid insurance and speaking Chinese as a primary language emerged as significant associations. In addition, higher cataract surgery utilization rates were associated with worse preoperative best-corrected visual acuity, a concurrent diagnosis of glaucoma, and a concurrent diagnosis of macular degeneration. Worse preoperative visual acuity was associated with Spanish or Chinese language preference, Medicaid status, and glaucoma diagnosis; poorer preoperative visual acuity was only weakly correlated with increased social vulnerability.

CONCLUSIONS

After adjusting for other biomedical and sociodemographic variables, having Medicaid insurance and being a non-English speaker were the factors most notably associated with reduced cataract surgery utilization and poorer preoperative visual acuity. Health insurance and language barriers, as well as other biomedical and sociodemographic factors, may explain a large proportion of the racial disparities in both cataract surgery utilization and preoperative visual acuity observed among Black and Hispanic patients. Chinese-speaking patients with limited English proficiency are a vulnerable subgroup that exhibits lower rates of cataract surgery utilization and higher degrees of visual loss prior to undergoing cataract surgery compared to other Asian patients.

Safety-Net Hospital Status Is Associated With Coronary Artery Bypass Grafting Outcomes at an Urban Academic Medical Center

INTRODUCTION

Socioeconomic disparities impact outcomes after cardiac surgery. At our institution, cardiac surgery cases from the safety-net, county funded hospital (CH), which primarily provides care for underserved patients, are performed at the affiliated university hospital. We aimed to investigate the association of socioeconomic factors and CH referral status with outcomes after coronary artery bypass grafting (CABG).

METHODS

The institutional Adult Cardiac Surgery database was queried for perioperative and demographic data from patients who underwent isolated CABG between January 2014 and June 2020. The primary outcome was major adverse cardiovascular event (MACE), a composite of postoperative myocardial infarction, stroke, or death. Secondary outcomes included individual complications. Chi-square, Wilcoxon rank-sum, and logistic regression analyses were used to compare differences between CH and non-CH cohorts.

RESULTS

We included 836 patients with 472 (56.5%) from CH. Compared to the non-CH cohort, CH patients were younger, more likely to be Hispanic, non-English speaking, and be completely uninsured or require state-specific financial assistance. CH patients were more likely to have a history of tobacco and drug use, liver disease, diabetes, prior myocardial infarction, and greater degrees of left main coronary and left anterior descending artery stenosis. CH cases were less likely to be elective. The incidence of MACE was significantly higher in the CH cohort (16.3% versus 8.2%, P = 0.001). There were no significant differences in 30-d mortality, home discharge, prolonged mechanical ventilation, bleeding, sepsis, pneumonia, new dialysis requirement, cardiac arrest, or multiorgan system failure between cohorts. CH patients were more likely to develop renal failure and less likely to develop atrial fibrillation. On multivariable analysis, CH status (odds ratio 2.39, 95% confidence interval 1.25-4.55, P = 0.008) was independently associated with MACE.

CONCLUSIONS

CH patients undergoing CABG presented with greater comorbidity burden, more frequently required nonelective surgery, and are at significantly higher risk of postoperative MACE.

Mortality by avoidable causes in Brazil from 1990 to 2019: data from the Global Burden of Disease Study

OBJECTIVES

The aim of this study was to analyse the trends of avoidable mortality in Brazil from 1990 to 2019 and its correlation with sociodemographic indexes (SDIs).

STUDY DESIGN

Epidemiological mortality trends.

METHODS

This study analysed data from the Global Burden of Disease database. The list of causes of avoidable death, as proposed by Nolte and McKee, was applied and included 32 causes. The current study used age-standardised mortality rates and the rates of change, in addition to a correlation analysis between avoidable death and the SDI.

RESULTS

Mortality rates decreased from 343.90/100,000 inhabitants in 1990 to 155.80/100,000 inhabitants in 2019. Infectious diseases showed the largest decline in mortality rates, but notable decreases were also found for diarrhoeal diseases (-94.9%), maternal conditions (-66.5%) and neonatal conditions (-60.5%). Mortality rates for non-communicable diseases (NCDs) also decreased (-48%) but maintained a similar absolute number of deaths in 2019 compared with 1990. Decreased mortality rates were also found for ischaemic heart disease (-49.1%), stroke (-61.4%) and deaths due to adverse effects caused by medical treatments (-26.2%). Avoidable mortality rates declined in all of the 27 Brazilian states, and a high correlation was found between deaths and SDI (R = -0.74; P < 0.000001).

CONCLUSIONS

A reduction in avoidable deaths was found throughout Brazil over the study period, although major regional inequalities were revealed. Richer states presented the best overall reduction in mortality rates. The biggest decreases in mortality were seen in maternal and paediatric infectious diseases in the poorest states due to the expansion of the Primary Health System and improvements in sanitation. Today, NCDs predominate and efforts should be made to formulate public policies for the prevention and control of NCDs.

Effect of Medicaid expansion on inflammatory bowel disease and healthcare utilization

BACKGROUND

Kentucky was among the first to adopt Medicaid expansion, resulting in reducing uninsured rates from 14.3% to 6.4%. We hypothesize that Medicaid expansion resulted in increased elective healthcare utilization and reductions in emergency treatments by patients suffering Inflammatory Bowel Disease (IBD).

METHODS

The Hospital Inpatient Discharge and Outpatient Services Database (HIDOSD) identified all encounters related to IBD from 2009 to 2020 in Kentucky. Several demographic variables were compared in pre- and post-Medicaid expansion adoption.

RESULTS

Our study analyzed 3386 pre-expansion and 24,255 post-expansion encounters for IBD patients. Results showed that hospitalization rates dropped (47.7%-8.4%), outpatient visits increased (52.3%-91.6%) and Emergency visits decreased (36.7%-11.4%). Admission following a clinical referral similarly increased with a corresponding drop in emergency room admissions. Hospital costs and lengths of stay also dropped following Medicaid expansion.

CONCLUSION

In the IBD population, Medicaid expansion improved access to preventative care, reduced hospital costs by decreasing emergency care, and increased elective care pathways.

Inpatient healthcare utilization among people with disabilities in Iran: determinants and inequality patterns

BACKGROUND

People with disabilities (PWD) have different health service needs and different factors affect the utilization of these services. Therefore, the aim of this present study was to identify determinants of inpatient healthcare utilization among PWDs in Iran.

METHODS

This research was a secondary data analysis of a cross-sectional study. The present study used data gathered for 766 PWDs (aged 18 years and older) within the Iranian Society with Disabilities (ISD) between September and December 2020. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals in order to identify determinants of inpatient healthcare utilization among PWDs.

RESULTS

Data for 766 people with disabilities were analyzed. A large number of participants were over 28 years of age (70.94%), male (64.36%), and single (54.02%). In the present study, more than 71% of participants had no history of hospitalization during the last year. In this study, males [aOR 2.11(1.14-3.91), participants with Civil Servants health insurance coverage [aOR 3.44 (1.16 - 10.17)] and individuals in the 3th quartile of disability severity [aOR 2.13 (1.01 - 4.51)] had greater odds of inpatient healthcare utilization compared to the other groups. The value of the concentration index (C) for inpatient healthcare utilization was - 0.084 (P.value = 0.046). The decomposition analysis indicated that gender was the greatest contributor (21.92%) to the observed inequality in inpatient healthcare utilization among participants.

CONCLUSION

Our findings suggested that the likelihood of hospitalization among the study participants could be significantly influenced by factors such as gender, the health insurance scheme, and the degree of disability severity. These results underscore the imperative for enhanced access to outpatient services, affordable insurance coverage, and reduced healthcare expenditures for this vulnerable population. Addressing these issues has the potential to mitigate the burden of hospitalization and promote better health outcomes for disadvantaged individuals.

Decomposition of socioeconomic inequalities in glaucoma knowledge in Taiwan

OBJECTIVES

Glaucoma knowledge is strongly associated with medication adherence and preventive behavior. Studies have frequently reported socioeconomic inequalities in glaucoma knowledge. This study aimed to decompose such inequalities. Decomposition analysis enables the design of policies directly targeting the underlying causes of inequality.

METHODS

We performed a cross-sectional survey from January 1, 2019 to June 30, 2019, at the departments of ophthalmology of 2 medical centers belonging to a hospital chain in northern Taiwan. Socioeconomic inequalities in glaucoma knowledge were ranked based on 3 aspects of socioeconomic status (SES): (1) education, (2) income, and (3) self-perceived financial status. The concentration index was calculated and decomposed using decomposition analysis. Elasticity and marginal effects were estimated for each decomposed factor.

RESULTS

In total, 1,203 patients completed the survey. Both measures of glaucoma knowledge and overall glaucoma knowledge score significantly contributed to the progressivity of knowledge inequalities (pro-high-SES inequalities). The concentration index for overall knowledge score with respect to education was 0.166 (p<0.001). Both objective and subjective measures of SES were associated with pro-high-SES inequalities. Our decomposition analysis revealed that demographic factors and attitudinal factors such as the level of concern regarding developing glaucoma contributed significantly to SES-based inequalities in glaucoma knowledge.

CONCLUSIONS

Our decomposition analysis provided empirical evidence regarding the underlying causes of SES-based inequalities in glaucoma knowledge. Efforts to improve glaucoma knowledge should consider specific factors that drive SES-based inequalities, such as age, sex, and concern about vision health, to ultimately achieve low SES-based inequalities.

Economic distress, obesity, and the rise in pain

Growing obesity may have contributed to widening socioeconomic disparities in pain in the US, but some researchers have suggested that deteriorating social and economic conditions among less advantaged Americans could be the root cause. We evaluated whether widening socioeconomic disparities in pain are associated with growing economic distress, particularly among those with low socioeconomic status (SES). We also assessed whether the link between economic distress and pain is mediated by obesity. Using data from nationally-representative samples targeting Americans aged 25-74 in 1995-96 (N = 3034) and 2011-14 (N = 2598), we fit a structural equation model to estimate the contributions of economic distress and obesity to period changes in the SES disparity in different types of pain. Socioeconomic disparities in backaches and joint pain widened substantially over recent decades, although there was no significant widening for headaches. Economic distress accounted for 34% of SES widening for backaches and 41% for joint pain, but the effect was largely independent of obesity. There was little evidence that economic distress led to obesity, which in turn fueled a rise in pain. Obesity alone explained another 8% of the widening SES disparity in backaches and 17% for joint pain. Economic distress played a larger role than obesity because economic distress increased over time for those with low SES whereas it decreased slightly for those with high SES. In contrast, obesity grew at all levels of SES, albeit more for those with low SES. Unfortunately, we cannot establish the direction of causation. Our model assumes that economic distress and obesity affect pain, but it is also possible that pain exacerbates obesity and/or economic distress. If SES disparities in pain continue to widen, it bodes poorly for the overall well-being of the US population, labor productivity, and the prospects for these cohorts as they reach older ages.

Strong social disparities in access to IVF/ICSI despite free cost of treatment: a French population-based nationwide cohort study

BACKGROUND

Access to IVF/ICSI is facilitated when the financial barrier is removed. In a national context where in vitro fertilisation (IVF)/intracytoplasmic sperm Injection (ICSI) treatment is cost-free, how many women do not access IVF/ICSI and what are the factors associated with non-access?

METHODS

Using French national health insurance databases, the cohort included 20,240 women aged 18-43 years living in France who underwent unsuccessful treatment (no pregnancy) with clomiphene citrate (CC) and/or gonadotropins with treatment started between January and August 2016. The outcome measure was non-access to IVF/ICSI during the 24-month following start of infertility care. Factors associated with non-access to IVF/ICSI were explored using mixed effects logistic regression.

RESULTS

In the cohort, 65.4% of women did not access IVF/ICSI. In multivariable analysis, non-access to IVF/ICSI was higher in younger women (18-25 years: (OR 2.17, 95% CI: 1.85-2.54) and in older women (40-43 years: (OR=3.60, 95% CI: 3.25-3.98)). Non-access was higher among women below the poverty line (OR=3.76, 95% CI: 3.34-4.23) and showed a significant upward trend with increasing deprivation of place of residence. Distance to the nearest fertility centre was not significantly associated with non-access to IVF/ICSI.

CONCLUSIONS

In a national context of cost-free ART treatment, a large proportion of women did not access treatment, with a strong social gradient that raises important issues. We need to understand the underlying social mechanisms to develop an efficient and equitable health policy regarding infertility care.

Disparities in Time to Diagnosis Among Patients With Multiple Myeloma

BACKGROUND

Multiple myeloma (MM) is one of the most diagnosed hematologic malignancies in the United States. Despite improvements in therapy, health disparities persist among patients with MM. Here, we aim to determine whether there are disparities in time to diagnosis (TTD) among MM patients with regard to income, race/ethnicity, and gender.

PATIENTS

Patients with a monoclonal protein detected in the serum and/or urine and a subsequent bone marrow biopsy confirmed diagnosis of MM were included in the study.

METHODS

We extracted data on patients with MM and assessed whether the predictor variables were associated with the primary outcome of TTD, which we define as the time between detection of a monoclonal protein in the serum or urine and bone marrow biopsy diagnosis of MM.

RESULTS

Compared to patients with commercial insurance, patients receiving Medicaid (HR: 0.408, 95% CI: 0.206-0.808; P = .010) and patients without insurance (HR: 0.428, 95% CI: 0.207-0.885; P = .022) were significantly more likely to have delayed TTD. TTD was also prolonged if the provider who ordered the testing for the detection of a monoclonal protein was not a hematologist (HR: 0.435, 95% CI: 0.284-0.668; P < .0001). No disparities were found with regard to race/ethnicity or gender.

CONCLUSION

This study suggests there may be socioeconomic disparities in TTD among patients with MM. Interventions such as patient navigation may be useful to reduce TTD among socioeconomically disadvantaged patient populations. Further studies need to be conducted to elucidate reasons for delays.

Trends in unmet health care needs among adults in the U.S., 2019-2021

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.

Racial, ethnic, and socioeconomic disparities impact post-liver transplant survival in patients with hepatocellular carcinoma

INTRODUCTION AND OBJECTIVES

Liver transplantation can be a curative treatment for patients with hepatocellular carcinoma (HCC); however, the morbidity and mortality associated with HCC varies by socioeconomic status and race and ethnicity. Policies like Share 35 were implemented to ensure equitable access to organ transplants; however, their impacts are unclear. We aimed to characterize differences in post-liver transplant (LT) survival among patients with HCC, when considering race and ethnicity, income, and insurance type, and understand if these associations were impacted by Share 35.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 30,610 adult LT recipients with HCC. Data were obtained from the UNOS database. Survival analysis was carried out using Kaplan-Meier curves, and multivariate Cox regression analysis was used to calculate hazard ratios.

RESULTS

Men (HR: 0.90 (95% CI: 0.85-0.95)), private insurance (HR: 0.91 (95% CI: 0.87-0.92)), and income (HR: 0.87 (95% CI: 0.83-0.92)) corresponded with higher post-LT survival, when adjusted for over 20 demographic and clinical characteristics (Table 2). African American or Black individuals were associated with lower post-LT survival (HR: 1.20 (95% CI: 1.12-1.28)), whereas. Asian (HR: 0.79 (95% CI: 0.71-0.88)) or Hispanic (HR: 0.86 (95% CI: 0.81-0.92)) individuals were associated with higher survival as compared with White individuals (Table 2). Many of these patterns held in the pre-Share 35 and Share 35 periods.

CONCLUSIONS

Racial, ethnic, and socioeconomic disparities at time of transplant, such as private insurance and income, influence post-LT survival in patients with HCC. These patterns persist despite the passage of equitable access policies, such as Share 35.

Socioeconomic conditions and children's mental health and quality of life during the COVID-19 pandemic: An intersectional analysis

BACKGROUND

Children and adolescents are highly vulnerable to the impact of sustained stressors during developmentally sensitive times. We investigated how demographic characteristics intersect with socioeconomic dimensions to shape the social patterning of quality of life and mental health in children and adolescents, two years into the COVID-19 pandemic.

METHODS

We used data from the prospective SEROCoV-KIDS cohort study of children and adolescents living in Geneva (Switzerland, 2022). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy by nesting participants within 48 social strata defined by intersecting sex, age, immigrant background, parental education and financial hardship in Bayesian multilevel logistic models for poor health-related quality of life (HRQoL, measured with PedsQL) and mental health difficulties (measured with the Strengths and Difficulties Questionnaire).

RESULTS

Among participants aged 2-17 years, 240/2096 (11.5%, 95%CI 10.1-12.9) had poor HRQoL and 105/2135 (4.9%, 95%CI 4.0-5.9) had mental health difficulties. The predicted proportion of poor HRQoL ranged from 3.4% for 6-11 years old Swiss girls with highly educated parents and no financial hardship to 34.6% for 12-17 years old non-Swiss girls with highly educated parents and financial hardship. Intersectional strata involving adolescents and financial hardship showed substantially worse HRQoL than their counterparts. Between-stratum variations in the predicted frequency of mental health difficulties were limited (range 4.4%-6.5%).

CONCLUSIONS

We found considerable differences in adverse outcomes across social strata. Our results suggest that, post-pandemic, interventions to address social inequities in HRQoL should focus on specific intersectional strata involving adolescents and families experiencing financial hardship, while those aiming to improve mental health should target all children and adolescents.

Socioeconomic Status, Protective Factors, and Mental Health Problems in Transition from Adolescence to Emerging Adulthood: Results of the Longitudinal BELLA Study

Lower familial socioeconomic status (SES) is associated with more mental health problems in adolescence. The aim of this study was to identify factors that may protect adolescents from families with lower SES from developing mental health problems in emerging adulthood. Data of the population-based longitudinal BELLA study included n = 426 participants aged 13 to 17 years at t0 (2009-2012) and 18 to 24 years at t1 (2014-2017). Hierarchical multiple linear regressions with interaction terms were conducted, examining three selected protective factors (self-efficacy, family climate, and social support). Self-efficacy had a small protective effect for adolescents from families with lower SES for mental health problems in emerging adulthood. However, social support had a small protective effect for adolescents from families with higher SES. No moderating effect was found for family climate. Instead, better family climate in adolescents predicted fewer mental health problems in emerging adulthood with a small effect regardless the SES in adolescence. Results indicate the need for prevention measures for adolescents from families with lower SES for becoming mentally healthy emerging adults.

Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015

BACKGROUND

Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance.

METHODS

We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities.

RESULTS

Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment.

CONCLUSIONS

While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti

BACKGROUND

In Haiti, cardiovascular disease is a leading cause of morbidity and mortality, with congenital and rheumatic heart disease comprising a large portion of disease burden. However, domestic disparities in cardiac care access and their impact on clinical outcomes remain poorly understood. We analyzed population-level sociodemographic variables to predict cardiac care outcomes across the 10 Haitian administrative departments.

METHODS

This cross-sectional study combined data from a 2016-17 Haitian national survey with aggregate outcomes from the Haiti Cardiac Alliance (HCA) database (n = 1817 patients). Using univariate and multivariable regression analyses, the proportion of HCA patients belonging to each of three clinical categories (active treatment, lost to follow-up, deceased preoperatively) was modeled in relation to six population-level variables selected from national survey data at the level of the administrative department.

RESULTS

In univariate analysis, higher department rates of childhood growth retardation were associated with a lower proportion of patients in active care (OR = 0.979 [0.969, 0.989], p = 0.002) and a higher proportion of patients lost to follow-up (OR = 1.016 [1.006, 1.026], p = 0.009). In multivariable analysis, the proportion of department patients in active care was inversely associated with qualified prenatal care (OR = 0.980 [0.971, 0.989], p = 0.005), and child growth retardation (OR = 0.977 [0.972, 0.983]), p = 0.00019). Similar multivariable results were obtained for department rates of loss to follow-up (child growth retardation: OR = 1.018 [1.011, 1.025], p = 0.002; time to nearest healthcare facility in an emergency: OR = 1.004 [1.000, 1.008, p = 0.065) and for preoperative mortality (prenatal care: OR = 0.989 [0.981, 0.997], p = 0.037; economic index: OR = 0.996 [0.995, 0.998], p = 0.007; time to nearest healthcare facility in an emergency: OR = 0.992 [0.988, 0.996], p = 0.0046).

CONCLUSIONS

Population-level survey data on multiple variables predicted domestic disparities in HCA clinical outcomes by region. These findings may help to identify underserved areas in Haiti, where increased cardiac care resources are required to improve health equity. This approach to analyzing clinical outcomes through the lens of population-level survey data may inform future health policies and interventions designed to increase cardiac care access in Haiti and other low-income countries.

Neighborhood socioeconomic deprivation, healthcare access, and 30-day mortality and readmission after sepsis or critical illness: findings from a nationwide study

BACKGROUND

To determine if neighborhood socioeconomic deprivation independently predicts 30-day mortality and readmission for patients with sepsis or critical illness after adjusting for individual poverty, demographics, comorbidity burden, access to healthcare, and characteristics of treating healthcare facilities.

METHODS

We performed a nationwide study of United States Medicare beneficiaries from 2017 to 2019. We identified hospitalized patients with severe sepsis and patients requiring prolonged mechanical ventilation, tracheostomy, or extracorporeal membrane oxygenation (ECMO) through Diagnosis Related Groups (DRGs). We estimated the association between neighborhood socioeconomic deprivation, measured by the Area Deprivation Index (ADI), and 30-day mortality and unplanned readmission using logistic regression models with restricted cubic splines. We sequentially adjusted for demographics, individual poverty, and medical comorbidities, access to healthcare services; and characteristics of treating healthcare facilities.

RESULTS

A total of 1,526,405 admissions were included in the mortality analysis and 1,354,548 were included in the readmission analysis. After full adjustment, 30-day mortality for patients was higher for those from most-deprived neighborhoods (ADI 100) compared to least deprived neighborhoods (ADI 1) for patients with severe sepsis (OR 1.35 95% [CI 1.29-1.42]) or with prolonged mechanical ventilation with or without sepsis (OR 1.42 [95% CI 1.31, 1.54]). This association was linear and dose dependent. However, neighborhood socioeconomic deprivation was not associated with 30-day unplanned readmission for patients with severe sepsis and was inversely associated with readmission for patients requiring prolonged mechanical ventilation with or without sepsis.

CONCLUSIONS

A strong association between neighborhood socioeconomic deprivation and 30-day mortality for critically ill patients is not explained by differences in individual poverty, demographics, measured baseline medical risk, access to healthcare resources, or characteristics of treating hospitals.

Deepened socioeconomic inequality in clean cooking fuel use in India from 2005-2006 to 2015-2016

Uptake of clean cooking fuels (CCF), such as liquefied petroleum gas (LPG), in place of traditional cooking fuels such as wood, charcoal, and kerosene can improve public health by reducing household air pollution exposures. Though studies have cross-sectionally examined socioeconomic determinants of cooking fuel adoption, little is known about socioeconomic disparities in CCF use over time. Data from the third (2005-06) and fourth (2015-16) rounds of the National Family Health Survey covering 109,041 and 601,509 households, respectively, were used to examine inequities in CCF use in India. While CCF use in India increased nationally from 25% in 2005-06 to 44% in 2015-16, the adoption of CCF varied widely across states and socio-economic groups. Approximately 2% of households in the poorest wealth quintile gained access to LPG during the study period, compared with an increase of 10% or more among households in the middle or richer wealth quintiles; the LPG access gap between the low (0.2%) and middle class (19.2%) was 19% in 2005-06 and nearly doubled to 35% (2.5% vs. 37.4%, respectively) in 2015-16. At the state level, there was a four-fold difference in the uptake of CCF over the two survey periods. The use of CCF increased by less than 10% in Himachal Pradesh, Bihar, Assam, Manipur, Mizoram, and Meghalaya as compared to the increases of at least 30% in Tamil Nadu (42%), undivided Andhra Pradesh (34%), and Kerala (30%). Further, in wealthier states (Delhi, Goa, Punjab, Haryana, Tamil Nadu, Kerala, and undivided Andhra Pradesh), CCF use increased by more than 20% among the poorest individuals compared with less than 1% among the poorest families in lower income states (Tripura, Meghalaya, Madhya Pradesh, Jharkhand, Chhattisgarh, Bihar). To promote a more equitable clean energy transition, poorer and rural Indian households should be prioritized for CCF promotion programs.

Socioeconomic status and disparities in COVID-19 vaccine uptake in Eastern Oslo, Norway

Objective

The objective of this study was to assess whether socioeconomic status still remain a barrier to COVID-19 vaccination in eastern Oslo, Norway.

Study design

A cross-section study.

Methods

We conducted a web-based survey among the residents of six eastern parishes in Oslo, Norway. Text (SMS) messages were sent to 59978 potential participants. 5447 surveys were completed for a response rate of 9.1%. After removing participants who had not been offered the COVID-19 vaccine, we ended up with a valid sample of 4000.

Results

We find a significant association between education and the likelihood of taking the COVID-19 vaccine in bivariate logistic regression. Further, we find a significant higher likelihood of taking the vaccine in the above-low-income group compared to the low-income group. However, when we add control variables to the regression, the significant results concerning both income and education are eliminated. In further analysis, we found that age worked as a moderator between socioeconomic status and vaccine uptake: In the youngest age group (18-29), we found a significant higher likelihood of taking the vaccine in the above-low-income group compared to the low-income group, and in the higher education group compared to the primary education group.

Conclusion

Socioeconomic status remains a barrier to COVID-19 vaccination in the eastern parishes of Oslo, Norway. Indicating that Norwegians of lower socioeconomic status still disproportionately face barriers such as transportation, language, flexible work hours, and paid sick time. However, our analysis shows that this association is only found in the age group 18-29.

The impact of health insurance affiliation and socioeconomic status on cervical cancer survival in Bucaramanga, Colombia

Cervical cancer is still an important cause of death in countries like Colombia. We aimed to determine whether socioeconomic status of residential address (SES) and type of health insurance affiliation (HIA) might be associated with cervical cancer survival among women in Bucaramanga, Colombia. All patients residing in the Bucaramanga Metropolitan Area diagnosed with invasive cervical cancer (ICD-0-3 codes C53.X) between 2008 and 2016 (n = 725) were identified through the population-based cancer registry, with 700 women having follow-up data for >5 years (date of study closure: Dec 31, 2021), yielding an overall 5-year survival estimate (95 % CI) of 56.4 % (52.7 - 60.0 %). KM estimates of 5-year overall survival were obtained to assess differences in cervical cancer survival by SES and HIA. Multivariable Cox-proportional hazards modeling was also conducted, including interaction effects between SES and HIA. Five-year overall survival was lower when comparing low vs. high SES (41.9 % vs 57.9 %, p < 0.0001) and subsidized vs. contributive HIA (45.1 % vs 63.0 %, p < 0.0001). Multivariable Cox modeling showed increased hazard ratios (HR) of death for low vs. high SES (HR = 1.78; 95 % CI = 1.18-2.70) and subsidized vs. contributive HIA (HR = 1.44; 95 % CI = 1.13-1.83). The greatest disparity in HR was among women of low SES affiliated to subsidized HIA (vs. contributive HIA and high SES) (HR=2.53; 95 % CI = 1.62-3.97). Despite Colombia's universal healthcare system, important disparities in cervical cancer survival by health insurance affiliation and socioeconomic status remain.

Socioeconomic disparities in fertility treatments and associated likelihood of livebirth following in vitro fertilization

OBJECTIVE

To determine whether neighborhood-level socioeconomic characteristics are associated with the likelihood of livebirth (LB) following in vitro fertilization (IVF). Specifically, we evaluated neighborhood-level household income, unemployment rate, and educational attainment.

DESIGN

A retrospective cross-sectional study was conducted for patients undergoing autologous IVF cycles.

SETTING

Large academic health system.

INTERVENTIONS

For each patient, ZIP code of residence was used as a proxy for neighborhood. Neighborhood characteristics were compared between patients with and without LB. Generalized estimating model was used to adjust the association between SES factors and likelihood of a live birth with respect to relevant clinical factors.

RESULTS

A total of 4942 autologous IVF cycles from 2768 patients were included: 1717 (62.0%) had at least one associated LB. Patients who achieved LB from IVF were younger, had higher anti-Mullerian hormone (AMH) levels, lower body mass index (BMI), and differed by ethnic background, primary language, and neighborhood socioeconomic characteristics. In a multivariable model, language, age, AMH, and BMI were associated with a live birth from IVF. None of the neighborhood-level socioeconomic variables were associated with the total number of IVF cycles or cycles required to achieve first LB.

CONCLUSION

Patients living in neighborhoods with lower annual household income have lower odds of livebirth after IVF compared to those living in more affluent areas, despite undergoing the same number of IVF stimulation cycles.

Transition-of-care program from emergency department to gastroenterology clinics improves follow-up

OBJECTIVES

Patients discharged from the emergency department (ED) with gastrointestinal (GI) symptoms need to appropriately transition their care to a GI outpatient clinic in a timely manner to have their health needs met and avoid significant morbidity. When this transition isn't optimal, patients are lost to follow-up, potentially placing them at risk for adverse events. We sought to study the effectiveness of implementing an electronic medical record (EMR) based transition-of-care (TOC) program from the ED to outpatient GI clinics.

METHODS

We performed a retrospective single center cohort study of patients discharged from the ED of a tertiary care academic medical center referred to outpatient GI clinic before (Pre-TOC patients) and after implementation of an EMR based TOC program (TOC patients). We further stratified patients based on the Distressed Communities Index (DCI), which is a composite measure of economic well-being. We compared rates of appointment scheduling and appointment attendance between the two groups, as well as 30-day readmission rates to the ED. We also performed a subgroup analysis to determine if socioeconomic status would affect patient follow-up rates.

RESULTS

We included 380 Pre-TOC and 399 TOC patients in our analysis. TOC patients were found to both schedule appointments (50% vs 27% p-value <0.01) as well as show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. There was no significant difference between 30-day readmission rates between the two groups. In addition, TOC patients from At-Risk and Distressed Communities were over 22 times more likely to schedule an appointment compared to Pre-TOC patients from similar neighborhoods (OR 22.18, 95% CI 4.23-116.32).

CONCLUSION

Our study shows that patients who are discharged from the ED with outpatient GI follow-up are more likely to both schedule and show up to appointments with implementation of an EMR-based direct referral program compared to no patient navigation, particularly among patients of lower socioeconomic status.

Differences in survivorship care experiences among older breast cancer survivors by clinical cancer characteristics, race/ethnicity, and socioeconomic factors: A SEER-CAHPS study

PURPOSE

To determine if disparities exist in survivorship care experiences among older breast cancer survivors by breast cancer characteristics, race/ethnicity, and socioeconomic factors.

METHODS

A total of 19,017 female breast cancer survivors (≥ 65 at post-diagnosis survey) contributed data via SEER-CAHPS data linkage (2000-2019). Analyses included overall and stratified multivariable linear regression to estimate beta (β) coefficients and standard errors (SE) to identify relationships between clinical cancer characteristics and survivorship care experiences.

RESULTS

Minority survivors were mostly non-Hispanic (NH)-Black (8.1%) or NH-Asian (6.5%). Survivors were 76.3 years (SD = 7.14) at CAHPS survey and were 6.10 years (SD = 3.51) post-diagnosis on average. Survivors with regional breast cancer vs. localized at diagnosis (β = 1.00, SE = 0.46, p = 0.03) or treated with chemotherapy vs. no chemotherapy/unknown (β = 1.05, SE = 0.48, p = 0.03) reported higher mean scores for Getting Needed Care. Results were similar for Overall Care Ratings (β = 0.87, SE = 0.38, p = 0.02) among women treated with chemotherapy. Conversely, women diagnosed with distant breast cancer vs. localized reported lower mean scores for Physician Communication (β = - 1.94, SE = 0.92, p = 0.03). Race/ethnicity, education, and area-level poverty significantly modified several associations between stage, estrogen receptor status, treatments, and various CAHPS outcomes.

CONCLUSION

These study findings can be used to inform survivorship care providers treating women diagnosed with more advanced stage and aggressive disease. The disparities we observed among minority groups and by socioeconomic status should be further evaluated in future research as these interactions could impact long-term outcomes, including survival.

Fecal continence outcomes and potential disparities for patients with anorectal malformations treated at referral institutions for pediatric colorectal surgery

PURPOSE

Fecal incontinence is a problem for many patients born with an anorectal malformation (ARM) that can impact quality of life. It is unknown if racial, ethnic, and socioeconomic disparities relate to fecal continence in these children. We sought to examine outcomes and potential disparities in care.

METHODS

We performed a multicenter retrospective study of children > 3y with ARM evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). The primary outcome was fecal continence. We evaluated for associations between fecal continence and race, sex, age, and insurance status.

RESULTS

509 patients with ARM from 11 institutions were included. Overall, 24% reported complete fecal continence, and fecal continence was associated with older age (p < .001). For school-aged children, 27% reported complete continence, while 53% reported none. On univariate analysis, patients with combined private and public insurance showed lower rates of continence when compared to those with private insurance (23 vs. 12%; p = 0.02). Age was associated with continence on univariate and multivariable analyses.

CONCLUSION

Rates of complete fecal continence in this population are low. Differences based on payor status may exist. There were no observed disparities related to sex and race. Further investigation is warranted to improve care for this patient population.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Multi-institutional retrospective comparative study.

Socioeconomic disparity in the association between fine particulate matter exposure and papillary thyroid cancer

BACKGROUND

Limited data exists suggesting that cumulative exposure to air pollution in the form of fine particulate matter (aerodynamic diameter ≤ 2.5 μm [PM2.5]) may be associated with papillary thyroid carcinoma (PTC), although this relationship has not been widely established. This study aims to evaluate the association between PM2.5 and PTC and determine the subgroups of patients who are at the highest risk of PTC diagnosis.

METHODS

Under IRB approval, we conducted a case-control study of adult patients (age ≥ 18) newly diagnosed with PTC between 1/2013-12/2016 across a single health care system were identified using electronic medical records. These patients were compared to a control group of patients without any evidence of thyroid disease. Cumulative PM2.5 exposure was calculated for each patient using a deep learning neural networks model, which incorporated meteorological and satellite-based measurements at the patients' residential zip code. Adjusted multivariate logistic regression was used to quantify the association between cumulative PM2.5 exposure and PTC diagnosis. We tested whether this association differed by gender, race, BMI, smoking history, current alcohol use, and median household income.

RESULTS

A cohort of 1990 patients with PTC and a control group of 6919 patients without thyroid disease were identified. Compared to the control group, patients with PTC were more likely to be older (51.2 vs. 48.8 years), female (75.5% vs 46.8%), White (75.2% vs. 61.6%), and never smokers (71.1% vs. 58.4%) (p < 0.001). After adjusting for age, sex, race, BMI, current alcohol use, median household income, current smoking status, hypertension, diabetes, COPD, and asthma, 3-year cumulative PM2.5 exposure was associated with a 1.41-fold increased odds of PTC diagnosis (95%CI: 1.23-1.62). This association varied by median household income (p-interaction =0.03). Compared to those with a median annual household income <$50,000, patients with a median annual household income between $50,000 and < $100,000 had a 43% increased risk of PTC diagnosis (aOR = 1.43, 95%CI: 1.19-1.72), and patients with median household income ≥$100,000 had a 77% increased risk of PTC diagnosis (aOR = 1.77, 95%CI: 1.37-2.29).

CONCLUSIONS

Cumulative exposure to PM2.5 over 3 years was significantly associated with the diagnosis of PTC. This association was most pronounced in those with a high median household income, suggesting a difference in access to care among socioeconomic groups.

Socioeconomic disparities in health outcomes in the United States in the late 2010s: results from four national population-based studies

BACKGROUND

Despite the importance of monitoring health disparities by multiple socioeconomic categories, there have been no recent updates on the prevalence of general health indicators by socioeconomic categories. The present study aims to update the prevalence estimates of health indicators by education and income categories across three age groups (children, young and middle-aged adults, and older adults) in the late 2010s by using four nationally representative data sources. We also examine socioeconomic differences in health by race/ethnicity subgroups.

METHODS

Data were obtained from four nationally representative data sources from the U.S.: The National Health Interview Survey (2015-2018); the National Health and Nutrition Examination Survey, NHANES (2017-2020); the Behavioral Risk Factor Surveillance System (2016-2020); and the Health & Retirement Study (2016). Respondent-rated health and obesity were selected as the health indicators of interest. Socioeconomic factors included percentages of the federal poverty level and years of educational attainment. We conducted logistic regression analyses to calculate adjusted prevalence rates of respondent-rated (or measured, in the case of obesity in NHANES) poor health and obesity by income and education categories after controlling for sociodemographic characteristics. The complex sampling designs were accounted for in all analyses.

RESULTS

Prevalence rates across racial/ethnic groups and age groups demonstrated clear and consistent socioeconomic gradients in respondent-rated poor health, with the highest rates among those in the lowest income and education categories, and decreased rates as income and education levels increased. On the other hand, there were less evident socioeconomic differences in obesity rates across all data sources, racial/ethnic groups, and age groups.

CONCLUSIONS

Our results confirmed earlier, persistent evidence indicating socioeconomic disparities in respondent-rated poor health across all age and race/ethnicity groups by using four nationally representative datasets. In comparison to a decade earlier, socioeconomic disparities in poor health appeared to shrink while they emerged or increased for obesity. The results suggest an urgent need for action to alleviate pervasive health disparities by socioeconomic status. Further research is needed to investigate potentially modifiable factors underlying socioeconomic disparities in health, which may help design targeted health promotion programs.

The association of disparities in neighborhood median household income and mortality in patients admitted to the hospital with atrial fibrillation

BACKGROUND

Lower neighborhood median household income (nMHI) is associated with increased adverse outcomes in patients with atrial fibrillation (AF). However, its effect on mortality is yet unknown.

METHODS

Data from the regional United States (U.S.) electronic medical records database, Research Action for Health Network (REACHnet), was extracted for adult patients with AF at Tulane Medical Center over 10 years. Annual nMHI & neighborhood high school graduation (HSG) data was collected from the US Census bureau. Only African Americans (AA) and Caucasians (CC) who had socioeconomic data were included. Low nMHI and low HSG were defined as ≤$25,000 & <90% respectively. High nMHI and HSG were defined as >$50,000 & ≥90% respectively. Primary endpoints were all cause and cardiovascular (CV) mortality. Cox-proportional hazard ratios were used to evaluate the endpoints.

RESULTS

We included 4616 patients diagnosed with AF. During a median follow up of 4.6 years, 434 patients died of which 32.7% patients had CV mortality. There was a stepwise decrease in incidence of both all-cause and CV mortality as nMHI increased. Patients with low nMHI had the greatest risk of all-cause mortality (HR 1.9, C.I. 1.2-3.2, P 0.004). The association between low nMHI and all-cause mortality persisted after adjusting for age, sex, race, HSG and stroke risk factors using CHA₂DS₂VASC, delta CHA₂DS₂VASC scores and oral anticoagulant use. CV mortality followed a similar trend as all-cause mortality, however, this association was not significant after adjusting for the above variables. Apart from low nMHI, CHA₂DS₂VASC delta CHA₂DS₂VASC were statistically significant independent predictors of both all-cause and CV mortality.

CONCLUSION

Low nMHI is an independent risk factor for all cause and CV mortality in AF. Higher burden of co-morbidities is the driving force behind this disparity. Future studies should evaluate the role of educational and therapeutic intervention in these populations to reduce mortality.

Racial, ethnic, and socioeconomic disparities in out-of-hospital cardiac arrest within the United States: Now is the time for change

This review highlights the current evidence on racial, ethnic, and socioeconomic disparities in cardiac arrest outcomes within the United States. Several studies demonstrate that patients from Black, Hispanic, or lower socioeconomic status backgrounds suffer the most from disparities at multiple levels of the resuscitation pathway, including in the provision of bystander cardiopulmonary resuscitation, defibrillator usage, and postresuscitation therapies. These gaps in care may altogether lead to lower survival rates and worse neurological outcomes for these patients. A multisystem, culturally sensitive approach to improving cardiac arrest outcomes is suggested in this article.

Parental and Other Caregiver Loss Due to COVID-19 in the United States: Prevalence by Race, State, Relationship, and Child Age

The more than one million COVID-19 deaths in the United States include parents, grandparents, and other caregivers for children. These losses can disrupt the social, emotional, and economic well-being of children, their families, and their communities, and understanding the number and characteristics of affected children is a critical step in responding. We estimate the number of children who lost a parent or other co-residing caregiver to COVID-19 in the U.S. and identify racial, ethnic, and geographic disparities by aligning COVID-19 death counts through mid-May 2022 with household information from a representative sample of individuals. We estimate that 216,617 children lost a co-residing caregiver to COVID-19; 77,283 lost a parent and more than 17,000 children lost the only caregiver with whom they lived. Non-White children were more than twice as likely as White children to experience caregiver loss, and children under 14 years old experienced 70% of caregiver loss. These losses are a salient threat to the functioning of families and the communities in which COVID-19 deaths are concentrated, compounding additional challenges to physical and mental health and economic stability disproportionately imposed by the pandemic on historically disadvantaged populations. Policymakers and systems should take steps to ensure access to appropriate supports.

Evaluating the Bariatric Safety Net: Analysis of Socioeconomic Factors and Outcomes at a Bariatric Safety Net Program Compared to an Affiliated Private Center

PURPOSE

Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH).

METHODS

Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts.

RESULTS

Of the 243 LSG performed, 141 (58%) occurred at PH versus 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Based off the results from the postoperative telephone survey, there were no significant differences in dietary and lifestyle habits between both cohorts. Postoperative weight loss outcomes were similar across cohorts. The two groups had similar percent excess weight loss (EWL) at all time points up to 36 months and similar rates of failure to achieve 50% EWL at 12 months. However, patients at PH had greater resolution of diabetes and hypertension after surgery.

CONCLUSION

Our study demonstrates outcomes after bariatric surgery are similar at a PH and its affiliated SNH. Despite differences in race and socioeconomic factors between the two cohorts, perioperative outcomes, short-term postoperative weight loss, and weight loss failure rates were equivalent between SNH and PH patients.

Improving access to public physical activity events for disadvantaged communities in Australia

Background

Physical activity has numerous health benefits, but participation is lower in disadvantaged communities. ‘parkrun’ overcomes one of the main barriers for disadvantaged communities, the cost of activities, by providing a free, regular community-based physical activity event for walkers, runners and volunteers. This study assesses equity of access (in terms of distance to the nearest parkrun) stratified by socioeconomic deprivation, and identifies the optimal location for 100 new events to increase equity of access.

Methods

We combined information about population location and socioeconomic deprivation, with information about the location of 403 existing parkrun events, to assess the current level of access by deprivation quintile. We then used a two-step location-allocation analysis (minimising the sum of deprivation-weighted distances) to identify optimal regions, then optimal towns within those regions, as the ideal locations for 100 new parkrun events.

Results

Currently, 63.1% of the Australian population lives within 5 km of an event, and the average distance to an event is 14.5 km. A socioeconomic gradient exists, with the most deprived communities having the largest average distance to an event (27.0 km), and the least deprived communities having the best access (living an average 6.6 km from an event). Access improves considerably after the introduction of new event locations with around 68% of the population residing within 5 km of an event, and the average distance to the nearest event approximately 8 km. Most importantly, the improvement in access will be greatest for the most deprived communities (now an average 11 km from an event).

Conclusions

There is a socioeconomic gradient in access to parkrun events. Strategic selection of new parkrun locations will improve equity of access to community physical activity events, and could contribute to enabling greater participation in physical activity by disadvantaged communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13981-5.

Impact of Race, Gender, and Socioeconomic Status on Symptom Severity at Time of Urologic Referral

BACKGROUND AND OBJECTIVES

The Dysfunctional Voiding and Incontinence Scoring System (DVISS) is a validated tool to evaluate lower urinary tract dysfunction (LUTD) severity in children. DVISS provides a quantitative score (0-35) including a quality-of-life measure, with higher values indicating more/worse symptoms. Clinically, variability exists in symptom severity when patients present to pediatric urology with LUTD. We hypothesized that symptom severity at consultation varied based on race, gender, and/or socioeconomic status.

METHODS

All urology encounters at a single institution with completed modified DVISS scores 6/2015-3/2018 were reviewed. Initial visits for patients 5-21 years old with non-neurogenic LUTD were included. Patients with neurologic disorders or genitourinary tract anomalies were excluded. Wilcoxon rank sum tests compared scores between White and Black patients and between male and female patients. Multiple regression models examined relationships among race, gender, estimated median household income, and insurance payor type. All statistics were performed using Stata 15.

RESULTS

In total, 4086 initial patient visits for non-neurogenic LUTD were identified. Median DVISS scores were higher in Black (10) versus White (8) patients (p < 0.001). Symptom severity was higher in females (9) versus males (8) (p < 0.001). When estimated median income and insurance payer types were introduced into a multiple regression model, race, gender, and insurance payer type were significantly associated with symptom severity at presentation.

CONCLUSIONS

Race, gender, and socioeconomic status significantly impact LUTS severity at the time of urologic consultation. Future studies are needed to clarify the etiologies of these disparities and to determine their clinical significance.

Socioeconomic disparities in use of rhythm control therapies in patients with incident atrial fibrillation: A Finnish nationwide cohort study

Background

In patients with atrial fibrillation (AF), socioeconomic disparities have been reported in the use of oral anticoagulant therapy and outcomes, but whether income also affects the utilization of antiarrhythmic therapies (AATs) for rhythm control is unknown. We assessed the hypothesis that AF patients with higher income are more likely to receive AATs.

Methods

The nationwide retrospective registry based FinACAF cohort study covers all patients with AF from all levels of care in Finland. Patients were divided in AF diagnosis year and age-group specific income quintiles according to their highest annual income during 2004-2018. The primary outcome was the use of any AAT, including cardioversion, catheter ablation, and fulfilled antiarrhythmic drug (AAD) prescription.

Results

We identified 188 175 patients (mean age 72.6 ± 13.0 years; 49.6% female) with incident AF during 2010-2018. Patients in higher income quintiles had consistently higher use of all AAT modalities. When compared to patients in the lowest income quintile, the adjusted incidence rate ratios (95% CI) in the highest quintile were 1.53 (1.48-1.59) for any AAT, 1.71 (1.61-1.81) for AADs, 1.43 (1.37-1.49) for cardioversion, and 2.00 (1.76-2.27) for catheter ablation. No temporal change during study period was observed in the magnitude of income disparities in AAT use, except for a decrease in income-related differences in the use of AADs.

Conclusion

Profound income-related disparities exist in AAT use among patients with AF in Finland, especially in the use catheter ablation.

Is mammography screening an effective public health intervention? Evidence from a natural experiment

Population-based breast screening programmes aim to improve clinical outcomes, alleviate health inequalities, and reduce healthcare costs. However, while screening can bring about immediate changes in mode of presentation and stage at diagnosis of breast cancer cases, the benefits and harms of these programmes can only be observed at a population level, and only over a long enough timeframe for the cascade of events triggered by screening to culminate in disease-specific mortality reductions. In this paper we exploit a natural experiment resulting from the phased geographic rollout of a national mammography screening programme to examine the impact of screening on breast cancer outcomes from both a patient cohort and a population perspective. Using data on 33,722 breast cancer cases over the period 1994-2011, we employ a difference-in-differences research design using ten-year follow-up data for cases diagnosed before and after the introduction of the programme in screened and unscreened regions. We conclude that although the programme produced the intended intermediate effects on breast cancer presentation and incidence, these failed to translate into significant decreases in overall population-level mortality, though screening may have helped to reduce socioeconomic disparities in late stage breast cancer incidence.

Fair play? Participation equity in organised sport and physical activity among children and adolescents in high income countries: a systematic review and meta-analysis

BACKGROUND

Physical activity and sport have numerous health benefits and participation is thought to be lower in disadvantaged children and adolescents. However, evidence for the disparity in physical activity is inconsistent, has not been reviewed recently, and for sport has never been synthesised. Our aim was to systematically review, and combine via meta-analyses, evidence of the socioeconomic disparities in physical activity and sport participation in children and adolescents in high income countries.

METHODS

We conducted searches of five electronic databases using physical activity, sport, and socioeconomic disparity related terms. Two independent reviewers assessed 21,342 articles for peer-reviewed original research, published in English that assessed socioeconomic disparities in physical activity and sport participation in children and adolescents. We combined evidence from eligible studies using a structural equation modelling approach to multilevel meta-analysis.

RESULTS

From the 104 eligible studies, we meta-analysed 163 effect sizes. Overall, children and adolescents living in higher socioeconomic status households were more likely to participate in sport (OR: 1.87, 95% CIs 1.38, 2.36) and participated for a longer duration (d = 0.24, 95% CIs 0.12, 0.35). The socioeconomic disparity in the duration of sport participation was greater in children (d = 0.28, 95% CIs 0.15, 0.41) compared with adolescents (d = 0.13, 95% CIs - 0.03, 0.30). Overall, children and adolescents living in higher socioeconomic status households were more likely to meet physical activity guidelines (OR: 1.21, 95% CIs 1.09, 1.33) and participated for a longer duration (d = 0.08, 95% CIs 0.02, 0.14). The socioeconomic disparity in the duration of total physical activity between low and high socioeconomic status households was greater in children (d = 0.13, 95% CIs 0.04, 0.21) compared with adolescents (d = 0.05, 95% CIs - 0.05, 0.15). There was no significant disparity in leisure time physical activity (d = 0.13, 95% CIs - 0.06, 0.32).

CONCLUSIONS

There was evidence of socioeconomic disparities in sport participation and total physical activity participation among children and adolescents. Socioeconomic differences were greater in sport compared to total physical activity and greater in children compared with adolescents. These findings highlight the need importance of targeting sport programs according to socio-economic gradients, to reduce inequities in access and opportunity to organised sport.

Life Course Socioeconomic Status and Healthy Longevity in China

In 2020, China's population aged 60 or older exceeded 264 million, representing 25% of the global population in that age-group. Older adults in China experienced periods of dramatic political and social unrest in early life, as well as economic transformations leading to drastic improvements in living standards during adulthood and older age. However, the implications of life course socioeconomic status (SES) trajectories for healthy longevity in later life have not been systematically studied in China. We utilize data from the China Health and Retirement Longitudinal Study (CHARLS) to comprehensively investigate how early-life conditions and adult SES combine to influence healthy longevity in later life. We find that both childhood and adulthood SES are associated with late-life health. The largest disparities in life expectancy (LE) and disability-free LE are found between those with persistently low SES throughout life and those with consistently high SES. At age 45, the gap in total LE between the most advantaged and least advantaged groups is six years for men and five years for women. Despite China's major policy changes prioritizing equity in income and health care in recent decades, our findings suggest that dramatic health inequalities among older adults remain. Our findings extend the literature on the effect of socioeconomic patterns across the life course on gradients in later-life health and highlight continuing disparities in healthy longevity among older adults in China.

Racial/ethnic and socioeconomic disparities in the use of newer diabetes medications in the Look AHEAD study

Background

Among patients with type 2 diabetes, minority racial/ethnic groups have a higher burden of cardiovascular disease, chronic kidney disease, and hypoglycaemia. These groups may especially benefit from newer diabetes medication classes, but high cost may limit access. We examined the association of race/ethnicity with the initiation of newer diabetes medications (GLP-1 receptor agonists, DPP-4 inhibitors, SGLT-2 inhibitors).

Methods

We conducted a secondary analysis of the Look AHEAD (Action for Health in Diabetes) trial including participants with at least one study visit after April 28, 2005. Cox proportional hazards models were used to estimate the association between race/ethnicity and socioeconomic factors with time to initiation of any newer diabetes medication from April 2005 to February 2020. Models were adjusted for demographic and clinical characteristics.

Findings

Among 4,892 participants, 63.6%, 15.7%, 12.6%, 5.2%, and 2.9% were White, Black, Hispanic, American Indian or Alaskan Native (AI/AN), or other race/ethnicity, respectively. During a median follow-up of 8.3 years, 2,180 (45.2%) participants were initiated on newer diabetes medications. Race/ethnicity was associated with newer diabetes medication initiation (p=.019). Specifically, initiation was lower among Black (HR 0.81, 95% CI 0.70 -0.94) and AI/AN participants (HR 0.51, 95% CI 0.26-0.99). Yearly family income was inversely associated with initiation of newer diabetes medications (HR 0.78, 95% CI 0.62-0.98) comparing the lowest and highest income groups. Findings were mostly driven by GLP-1 receptor agonists.

Interpretation

These findings provide evidence of racial/ethnic disparities in the initiation of newer diabetes medications, independent of socioeconomic factors, which may contribute to worse health outcomes.

Receipt, Spending, and Clinical Correlates of the Economic Impact Payment Among Middle- and Low-Income U.S. Adults

OBJECTIVE

This study examined characteristics and planned expenses of U.S. adults who received the economic impact payment (EIP) during the COVID-19 pandemic.

METHODS

Using a nationally representative sample of 6,607 middle- and low-income U.S. adults, the authors examined the proportion and correlates of EIP receipt among eligible adults and the associations among planned EIP-financed expenses, challenges with paying expenses, and clinical characteristics.

RESULTS

Of the sample, 78.8% reported that they received the EIP, and 82.3% of EIP recipients reported that it had a positive impact on their life. Being a veteran (odds ratio [OR]=2.59), being married (OR=1.82), having a history of schizophrenia spectrum disorder (OR=1.74) or posttraumatic stress disorder (OR=1.51), and screening negative for recent suicidal ideation (OR=0.49) were associated with EIP receipt. Planned expenses with the EIP were savings, paying debt, and rent and accounted for 63.4% of the total amount. Screening positive for mental health or drug use problems was positively associated with greater planned expenses for substances and gambling. EIP receipt also was associated with fewer problems paying daily expenses, but participants who screened positive for mental health or alcohol use problems were more likely to report problems paying past-month daily expenses.

CONCLUSIONS

Unconditional cash transfers such as the EIP may be important for sustaining the living situation of middle- and low-income populations. The management of funds is important to consider, especially among adults experiencing mental health and substance abuse problems, and such cash transfers may represent opportunities for financial literacy and money management interventions.

Safety and Quality of Romaine Lettuce Accessible to Low Socioeconomic Populations Living in Houston, TX

ABSTRACT

Previous empirical evidence has demonstrated that low-socioeconomic status (SES) communities have higher rates of gastroenteritis; however, there is a paucity of literature on the safety and quality of food (fresh produce) accessible to these communities. The overarching goal of this study was to investigate the microbial safety and quality of romaine lettuce from low- and high-SES neighborhoods in the Houston, TX, area. Loose-leaf romaine lettuce was purchased from low- and high-SES neighborhood retailers, and aerobic plate count, coliform, Escherichia coli, yeast, and mold assays were conducted. In addition, enrichment was performed on all samples for Listeria monocytogenes, Staphylococcus aureus, Salmonella spp., and E. coli O157:H7, and reverse transcriptase PCR analysis was carried out. The results showed that E. coli, coliform, yeast, and mold were present in significantly higher counts (P < 0.05) in produce obtained from low-SES neighborhoods compared with high-SES neighborhoods. The reverse transcriptase PCR results showed that 38% of samples from high-SES areas were positive for S. aureus versus 87% of samples from low-SES areas. None of the samples from high-SES areas were positive for the other pathogens. The samples from low-SES areas were positive for E. coli O157:H7 (4%), Salmonella spp. (53%), L. monocytogenes (13%), and S. aureus (87%). These results demonstrate a significant disparity in the quality and safety of romaine lettuce accessible to low- versus high-SES populations. Future studies can be designed to identify the specific cause of this challenge by investigating the food supply chain.

HIGHLIGHTS

How do patients with chronic illnesses respond to a public health crisis? Evidence from diabetic patients in Japan during the COVID-19 pandemic

How do people change their healthcare behavior when a public health crisis occurs? Within a year of its emergence, coronavirus disease 2019 (COVID-19) has gradually infiltrated our lives and altered our lifestyles, including our healthcare behaviors. In Japan, which faces China across the East China Sea and accepted 924,800 Chinese tourists in January 2020, the emergence and spread of COVID-19 provides a unique opportunity to study people's reactions and adaptations to a pandemic.

Patients with chronic illnesses who require regular doctor visits are particularly affected by such crises. We focused on diabetic patients whose delay in routine healthcare invites life-threatening complications and examined how their patterns of doctor visits changed and how demographic, socioeconomic, and vital factors disparately affected this process. We relied on the insurance claims data of a health insurance association in Tokyo. By using panel data of diabetic patients from April 2018 to September 2020, we performed visual investigations and conditional logistic regressions controlling for all time-invariant individual characteristics.

Contrary to the general notion that the change in healthcare behavior correlates with the actual spread of the pandemic, the graphical and statistical results both showed that diabetic patients started reducing their doctor visits during the early stage of the pandemic. Furthermore, a substantial decrease in doctor visits was observed in women, and large to moderate reductions were seen in patients who take insulin and are of advanced age, who are at high risk of developing severe COVID-19. By contrast, no differentiated effect was found in terms of income status. We further investigated why a change in pattern occurred for each subgroup.

The patterns of routine healthcare revealed by this study can contribute to the improvement of communication with the target population, the delivery of necessary healthcare resources, and the provision of appropriate responses to future pandemics. (299 words).

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Diabetic patients started decreasing doctor visits since the emergence of COVID-19.

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Female patients reduced doctor visits most rapidly regardless of their labor status.

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Patients at high risk of severe COVID-19 set very long interval in doctor visits.

Double jeopardy from the COVID-19 pandemic: risk of exposure and income loss in Portugal

BACKGROUND

Increasing evidence indicates that the first wave of the COVID-19 pandemic had immediate health and social impact, disproportionately affecting certain socioeconomic groups. Assessing inequalities in risk of exposure and in adversities faced during the pandemic is critical to inform targeted actions that effectively prevent disproportionate spread and reduce social and health inequities. This study examines i) the socioeconomic and mental health characteristics of individuals working in the workplace, thus at increased risk of COVID-19 exposure, and ii) individual income losses resulting from the pandemic across socioeconomic subgroups of a working population, during the first confinement in Portugal.

METHODS

This study uses data from 'COVID-19 Barometer: Social Opinion', a community-based online survey in Portugal. The sample for analysis comprised n = 129,078 workers. Logistic regressions were performed to estimate the adjusted odds ratios (AOR) of factors associated with working in the workplace during the confinement period and with having lost income due to the pandemic.

RESULTS

Over a third of the participants reported working in the workplace during the first confinement. This was more likely among those with lower income [AOR = 2.93 (2.64-3.25)], lower education [AOR = 3.17 (3.04-3.30)] and working as employee [AOR = 1.09 (1.04-1.15)]. Working in the workplace was positively associated with frequent feelings of agitation, anxiety or sadness [AOR = 1.14 (1.09-1.20)] and perception of high risk of infection [AOR = 11.06 (10.53-11.61)]. About 43% of the respondents reported having lost income due to the pandemic. The economic consequences affected greatly the groups at increased risk of COVID-19 exposure, namely those with lower education [AOR = 1.36 (1.19-1.56)] and lower income [AOR = 3.13 (2.47-3.96)].

CONCLUSIONS

The social gradient in risk of exposure and in economic impact of the pandemic can result in an accumulated vulnerability for socioeconomic deprived populations. The COVID-19 pandemic seems to have a double effect in these groups, contributing to heightened disparities and poor health outcomes, including in mental health. Protecting the most vulnerable populations is key to prevent the spread of the disease and mitigate the deepening of social and health disparities. Action is needed to develop policies and more extensive measures for reducing disproportionate experiences of adversity from the COVID-19 pandemic among most vulnerable populations.

Associations Among Select State Policies and the Nutritional Quality of Household Packaged Food Purchases in the United States from 2008 Through 2017

BACKGROUND

Policy interventions are important public health tools because they can reach large numbers of people. State context has been associated with health outcomes, yet few studies have examined the extent to which state-level policies are associated with dietary quality.

OBJECTIVES

The objective of this study was to evaluate whether state policies are associated with the nutritional quality of household packaged food purchases.

DESIGN

This observational study used data from Nielsen Homescan, an open-cohort household panel where participants track purchases, and a combination of state-level food and social safety net policy variables from 2008 through 2017.

PARTICIPANTS AND SETTING

This study included 615,634 household-year observations in the United States from 2008 through 2017. Household-year observations were excluded in the case that a household did not make a minimum number of purchases and in the case that they had incorrect geographic information. The final analytic sample was 611,719 household-years.

MAIN OUTCOME MEASURES

Study outcomes included a set of nutrition-related measures of public health interest, including nutrients of concern (eg, sugar, saturated fat, and sodium) and calories from specific food groups (eg, fruits, nonstarchy vegetables, processed meats, mixed dishes, sugar-sweetened beverages, and desserts and snacks).

STATISTICAL ANALYSIS

This study used multilevel generalized linear models with state fixed effects on three samples: all households, only households with low income, and only households with low educational attainment.

RESULTS

Few significant associations were found between healthy food retail policies and the nutritional quality of purchases, and mixed associations were found between social safety net policies and lower or higher quality packaged food purchases.

CONCLUSIONS

Little evidence was found that state policy context in 2008 through 2017 was associated with the quality of packaged food purchases. However, variation in state policies is increasing over time, warranting future research into the relationship between these policies, the quality of packaged food purchases, and the rest of the diet.