Search

Medicaid and Supplemental Nutrition Assistance Program (SNAP) are two large-scale safety net programs in the U.S. that provide public assistance to the low-income population. Over the years both programs have undergone several policy changes and have evolved to cover more needy individuals. This three-paper dissertation is a culmination of three research studies, two of which examine the effect of the Affordable Care Act’s (ACA) Medicaid expansion on outcomes of realized access to dental care i.e., dental visits and out-of-pocket dental care spending, respectively, while the third paper explores the relationship between SNAP participation and dental visits (realized access), and between SNAP participation and unmet dental care need due to cost (perceived access)., The few studies that have examined the impact of the Medicaid expansion on dental visits utilization have shown somewhat mixed findings and are mostly limited to examining early impacts (1-2 years post-expansion). Thus, Study I of this dissertation examined the longer-term impacts of states’ Medicaid expansions on dental visits utilization, by their adult dental benefits coverage level. Restricted data from the Medical Expenditure Panel Survey (MEPS) for the years 2011 through 2017 were obtained; the sample included adults aged 21-64 years with income up to 138% of Federal Poverty Level. A quasi-experimental Difference-In-Difference (DID) study design was used to examine the overall and year-by-year impacts of the Medicaid expansion on annual dental visits based on a states’ adult dental benefits coverage level (i.e., extensive, limited, and emergency-only/no benefits). Overall, expansion states, compared to non-expansion states, saw a 3-6 percentage point increase in annual dental visits in the post-expansion period (2014-2017), relative to the pre-expansion period (2011-2013). Year-by-year examinations revealed that the Medicaid expansion was associated with a significant increase in the likelihood of an annual dental visit among low-income adults in states with extensive benefits in 2014 (nearly 5 percentage points), and in states with limited and emergency-only/no dental benefits in both 2014 (6 percentage points for both) and 2016 (4 and 5 percentage points, respectively)., Expanding Medicaid also has the potential to reduce out-of-pocket dental care spending among low-income adults gaining coverage through Medicaid, especially among states that provide comprehensive adult dental benefits. Thus, Study II of this dissertation examined the impact of states’ Medicaid expansion on out-of-pocket dental care spending among low-income adults residing in states that provided extensive adult dental benefits. A DID study design with a two-part (hurdle) modeling approach was utilized to analyze post-expansion year-by-year changes in: a) the probability of incurring any out-of-pocket dental spending, and b) the amount of out-of-pocket spending (conditional on any spending) between expansion states with extensive benefits and non-expansion states. Overall, a greater proportion of adults in expansion states with extensive dental benefits (58%) reported zero dollars in out-of-pocket dental care spending, compared to those in non-expansion states (31%). Our DID analysis found that, compared to non-expansion states, adults residing in states that provided extensive adult dental benefits and expanded Medicaid were significantly less likely to incur any out-of-pocket dental spending in the first two years of implementing the expansion (2014 and 2015)., There is growing interest in examining SNAP’s spillover impacts on improving healthcare access and outcomes, postulated to be due to SNAP’s ability to reduce food-insecurity thereby potentially freeing up some financial and cognitive resources to seek care. Thus, Study 3 of this dissertation examined the association between participation in SNAP and realized and perceived access to dental care among low-income adults. A sample of SNAP income-eligible adults aged 19-64 was created by pooling MEPS data for the years 2011 to 2017. Applying a propensity score method to control for important differences in characteristics between participants and eligible non-participants, and using a Doubly-Robust approach, multivariable logistic regressions modelling the impact of SNAP participation on annual dental visits and unmet dental care need due to cost were performed. Interestingly, we found that SNAP participants, compared to eligible non-participants, have significantly lower odds of having an annual dental visit (approximately 20%) and significantly greater odds of reporting unmet dental care need due to cost (approximately 40%)., In conclusion, the results of the three studies in this dissertation provide some important insights into the dental care access impacts of the ACA’s Medicaid expansion and provide foundational evidence on the relationship between participation in the Supplemental Nutrition Assistance Program and dental care access among low-income adults. Results from Study I are suggestive of a positive link between the expansion of Medicaid and increased dental visits. However, longer-term impacts were less consistent and varied based on states’ adult dental coverage level thereby warranting further research. Study II results are encouraging and show that providing comprehensive dental benefits in Medicaid adult dental programs is protective against incurring any out-of-pocket expense for those who utilize dental care, with the potential to benefit more low-income individuals when these states expand Medicaid eligibility. Lastly, Study III results show that SNAP participation is associated with lower dental visits utilization and greater unmet dental care need due to cost. While we postulate that this may be due to several reasons, such as, SNAP benefits not being enough to offset non-food costs, and perhaps, the most disadvantaged of all SNAP-eligible families who tend to have fewer resources being more likely to enroll in the program, further research is needed to fully investigate and understand the underlying causal mechanisms through which these associations operate.

Aim: To understand the experience of low-income older adults living in poverty in a high-income country. Design: A qualitative study based on Gadamer's hermeneutic phenomenology. Methods: A convenience sample of twenty-seven low-income older adults were interviewed in-depth between September 2021 and January 2022. Fleming's method for conducting phenomenological qualitative studies was followed and ATLAS.ti software was used for data analysis. Results: Three main themes were extracted from the analysis: (i) ‘living in the shadow of poverty’, (ii) ‘unprotected by the ‘social shield’ of the welfare state’ (iii) ‘the struggle to attain good health’. Conclusion: Living in poverty affects all spheres of life. Older adults living in poverty feel excluded from social support policies and laws. This has a negative impact on the older adults' mental health and can lead to social isolation. Implications for the Profession and/or Patient Care: Nursing interventions to promote health amongst older adults living in poverty should include an assessment of the patient's social determinants and a focus on increasing social participation. Older people living in poverty experience difficulties accessing formal social support so nurses should implement patient navigation interventions that aim to help them overcome the complexities of the system. Nursing interventions to improve mental health amongst older adults living in poverty are much needed. Impact: Living in poverty increases older adults' vulnerability. Older adults living in poverty suffer from mental health issues as they live under constant pressure to meet their basic needs and lack formal social support. These findings are important for nurses, who play a pivotal role in the design, implementation and evaluation of policies and interventions that promote health equity. Reporting Method: The study has been conducted following the COREQ guidelines. Patient or Public Contribution: There has been no public or patient involvement in the design or development of the study., Knowledge Transfer Programme from the University of Almería, Grant/Award Number: TRFE-SI-2021/004

The Chinese Dietary Guidelines propose a balanced diet for healthy living, but the affordability of this diet needs to be considered, especially for low-income households. To investigate the affordability of a healthy diet, this study analyzes the daily retail prices of 46 food items in 36 Chinese cities from 2016 to 2021. This study compares expenditure, diet composition, and nutritional status in two scenarios aligned with the guidelines. The results show that the mean minimum cost of a balanced diet exceeds the current per capita food expenditure for at least 182.85 million urban households. This suggests that low-income people would need to increase their expenditure by at least 20–121% to achieve the recommended diets. This study also identifies affordable and nutrient-dense foods such as standard flour, eggs, black beans, and cabbage, which policymakers should focus on when monitoring food prices. The findings recommend a combination of social and food system policies to reduce prices and make healthy diets accessible. This study identifies the gaps in the Chinese Dietary Guidelines for ensuring accessibility for vulnerable groups and provides a template for policymakers and researchers to track diet affordability using available food price data in China, contributing to China’s 2030 Health Plan and the UN’s Sustainable Development Goals.

Due to a rapidly growing population and economy, an increase in emissions from urban growth, industrial growth, and energy use hurt the environment’s health. This research examines how tourism, population, income, renewable energy, and electricity consumption affect carbon emissions in twenty-six low-income countries. There is no cross-sectional dependence (CSD) problem, so quantile regressions (QR) and generalized method of moments (GMM) are used. Results show that the environment is obtaining benefits because of tourism. CO2 emissions are rising because the per capita income, electricity consumption, and population are growing. CO2 emissions can be lowered by using more renewable energy and growing the economy faster. Environmental Kuznets Curve (EKC) is also valid in low-income countries. Thus, increasing income will not be harmful to the environment. Similarly, increasing tourism, renewable energy, and rising GDP per capita benefit low-income countries. The government can focus on sustainable tourism. Policymakers may convince more people to use renewable energy resources and grow the sustainable tourism industry. This study recommends that the government reduce greenhouse gas emissions, promote tourism that is good for the environment, take initiatives to limit population growth, and use renewable energy.

Background. Episodic future thinking (EFT) has shown efficacy in laboratory settings. We conducted a pilot goal-oriented EFT (GoEFT) intervention in a real-world setting to help low-income overweight or obese mothers lose weight. This paper presents intervention acceptability and efficacy. Methods. The study used a single-group, before–after design. During the 3-week intervention, participants (N = 15) completed weekly web-based lessons and online health coaching sessions to manage stress and emotion, eat healthier, and be more physically active. Participants completed online surveys at baseline and immediately after the intervention. They also completed an interview to evaluate intervention acceptability. We applied paired t-tests to evaluate efficacy and used content analysis to discover interview themes. Results. Participants consistently identified the intervention as acceptable, noting the usefulness of pre-written goals, GoEFT strategies, and goal progress evaluations. The intervention effectively promoted weight loss (d = −0.69), fruit and vegetable intake (d = 0.45–0.49), and emotion control (d = 0.71). It also reduced fat (d = −0.51) and added sugar intake (d = −0.48) and alleviated stress (d = −0.52). Moreover, the intervention increased autonomous motivation (d = 0.75–0.88) and self-efficacy (d = 0.46–0.61). Conclusion. The GoEFT intervention was acceptable to participants, showing strong preliminary efficacy.

To investigate the trend of healthcare needs among elders in low-income countries (LICs) and how changes in healthcare access and quality (HAQ) have correlated with these changes from 1990 to 2019, this study used estimates from the global burden of disease (GBD) 2019 study, including prevalence, years of life lost (YLLs), years lived with disability (YLDs), life expectancy (LE), health-adjusted life expectancy (HALE) and the HAQ index for years 1990 and 2019. We found increases in numbers of YLLs, YLDs, and prevalent cases due to NCDs, and the rate of increase was higher for all indicators of non-communicable diseases (NCDs) when compared with communicable, maternal, neonatal and nutritional diseases among elders. We also observed increases in LE and HALE among all countries. However, this was also challenged by increases in unhealthy life years (ULYs) and their constant percentage of LE. The HAQ index of LICs was also found to be low, although it had increased during the period. A reduction in the burden of acute diseases explains the increase in LE, but increases in ULYs and the NCD burden were also observed. LICs need to improve their HAQ to counter the growing threat of longer but less healthy lives.

Low-income housing plays an important, but frequently overlooked, role in energy use reduction. Barriers persist for low-income households to participate in energy efficiency programs and adopt efficient lifestyles. However, there has been only limited research into energy efficiency barriers faced by low-income households. Existing energy research studies primarily focus on homeowners whose demographic and socio-economic profiles are likely to be very different from low-income households or renters—limiting the applicability of previous findings to low-income households. This study aims to identify and evaluate the importance of the energy efficiency barriers faced by low-income households. A questionnaire survey was conducted with 212 low-income households in Australia. After randomly dividing the data into calibration and validation samples, an exploratory factor analysis (EFA) of the calibration sample identifies four energy efficiency barrier factors of financial, decision-making, information, and split incentives. These four factors are then validated by confirmatory factor analysis (CFA) of the validation sample in terms of goodness-of-fit, reliability, and validity to confirm financial as the most highly rated energy efficiency barrier. This research contributes to bridging the knowledge gap of the energy efficiency barriers of low-income households and providing a validated CFA model as a tool for assessment. The results provide a better understanding of the barriers involved and research evidence to facilitate the formulation of policies to overcome them.

Social safety nets as response to extreme poverty alleviation in African low-income countries still strive to fit and reinvent themselves in order to ensure their main goal achievement. The concept"s definition suffers so far of common stand fluctuating importantly referring to institutions, time, place and circumstances. In the context of African low income countries like Benin, safety nets programs play narrowed functions. They address issue of living conditions of most vulnerable, ensure that households" means of subsistence are protected and help them to invest in human capital through children" schooling meanwhile in transition and developed economies these programs occur as sophisticated. In cash and in kind transfers can"t be efficiently achievable owing largely to their unaffordable financial cost, to existing administrative capability concern as well as to significant technical challenges involving managerial, conceptual, monitoring, reporting skills" shortage and data availability and reliability. However, such nations dispose likelihood to overcome these undermining challenges simply throughout their rich natural resources" re-appropriation and locally transformation, {"references":["Alderman, H. (2002). Subventions en tant que filets sociaux de sécurité: efficacité et défis. Série d'introduction aux filets sociaux de sécurité, Washington, DC: World Bank","Cherrier, C. (2020, janvier). filets sociaux et securite alimentaire : une historique des enjeux. Iinter-ReseauxDeveloppement Rural. Consulté le 2 juin 2022, à l\"adresse https://www.inter","reseaux.org/wp-content/uploads/gds79_filets_sociaux-san-historique_version_longue.pdf","Fox, L. (2003). Uneintroductionauxfiletssociaux de sécurité dans leséconomies de","transition (No. 0306). SocialProtectionDiscussionpaper","Gillion, C., Turner, J., Bailey, C., &Latulippe, D. (2000).Social security pensions: Development and reform. Geneva: ILO.","Grosh, M., Del Ninno, C., Tesliuc, E., &Ouerghi, A. (2008). Forprotectionandpromotion: Thedesignandimplementation of effectivesafetynets. World Bank Publicationsfiletpremier"]}

Shelter is one of the fundamental needs of human survival aside food and clothing. However, provision of adequate housing to accommodate people in urban areas has been a challenge in developing countries, including Ghana. This has caused many Ghanaians, especially the low-income group, to resort to the rental sector for their housing needs. It is widely discussed in the literature that each city user is to be accorded the needed right to utilise what exists in the city, including decent accommodation. This article examines the strategies put in place by lowincome house tenants to cope with the challenges of renting houses in the Wenchi Municipality, in order to rightly utilise urban housing. The study used a quantitative approach and a questionnaire survey to collect data from 245 tenant household heads. Purposive and systematic sampling techniques were used to select the respondents for the study. The data was analysed using SPSS. The study revealed that rental problems faced by tenants and adaptation measures developed to cope in cities and bigger towns are not different from what exists in the smaller towns. The study recommended that rent control should be strengthened to perform its duties in the rental sector well enough to protect the interest of the urban low-income renters.

Racial/ethnic and socioeconomic differences were shown to have an influence on child fruit and vegetable intake. This study examined the associations between parent and child fruit and vegetable intake and the home nutrition environment among Hispanic/Latino and African American families. Through a cross-sectional study design, self-reported surveys (n = 6074) were obtained from adult–child dyad participants enrolled in Brighter Bites, an evidence-based health promotion program, in the fall of 2018. For every once/day increase in frequency of parent FV intake, there was an increase in child FV intake by 0.701 times/day (CI: 0.650, 0.751, p < 0.001) and 0.916 times/day (CI: 0.762, 1.07; p < 0.001) among Hispanic/Latinos and African Americans, respectively. In Hispanic/Latino participants, significant positive associations were found between fruits as well as vegetables served at mealtimes ≥3 times/week (p < 0.001), family mealtimes 7 times/week (p = 0.018), parent–child communication about healthy eating and nutrition at least sometimes during the past 6 months (p < 0.05), and frequency of child FV intake, after adjusting for covariates. In African American participants, a significant positive association was found in fruits served at mealtimes ≥1 times/week (p < 0.05), and vegetables served at mealtimes ≥5 times/week (p < 0.05). Meals cooked from scratch a few times a day/all the time were significantly positively associated with frequency of child FV intake for both Hispanic/Latino (p = 0.017) and African American (p = 0.007) groups. The relationship between home nutrition environment and child FV intake varied by race and ethnicity. Future programs should consider designing culturally tailored interventions to address racial/ethnic-specific influences that match the child’s race, culture, and ethnicity.

Drawing on a comprehensive panel data of 137 low income and developing countries, this study queries the macro-economic drivers of Public Private Partnership (PPP) in these countries. PPP is mainly used as a method to address infrastructure needs of nation states which cannot allocate their financial resources towards infrastructure investments and/or cannot secure finance through other instruments. Previous studies in the field remain partial as they included a limited number of macro-economic factors and a smaller number of countries. Our findings suggest that general government balance, population size, money supply and the share of investments in GDP are significant determinants of PPP activity.

To explain an emerging trend towards deteriorating living conditions among low-income households across several (West-)European countries, it makes sense to investigate domains of socio-economic regulation that impact on expenditures, rather than incomes. I focus specifically on the domain of housing. Multilevel analyses for 28 countries (EU-SILC) demonstrate that redistributive housing policies such as rental market regulation and housing allowances weaken the cross-sectional (between-country) positive association between a low-income and living conditions-deprivation, while also benefiting living conditions across the broader population. Regarding changes over time, increased uptake of housing allowances throughout the Great Financial Crisis (2008/2009) seems to have shielded in particular renters from deteriorating living conditions, and might have compensated for declining availability of social housing. Higher house prices and price volatility, indicating housing market financialization, are associated with increased living conditions-deprivation for renters and low-income owners, both cross-sectionally and within countries over time. Anti-poverty policies should thus take a broader perspective, and take better account of provision for housing and other basic needs.

This article presents a novel methodology to assess the financial risk to crops in highly weather-volatile regions. We use data-driven methodologies that use singular value decomposition techniques in a low-income economy. The risk measure is first derived by applying data-driven frameworks, a Principal Component Analysis (PCA), and Singular Spectrum Analysis (SSA) to productive coffee crops in Colombia (163 weather stations) during 2010–2019. The objective is to understand the future implications that index insurance tools will have on strategic economic crops in the country. The first stage includes the identification of the PCA components at the country level. The risk measure, payouts-in-exceedance ratio, or POER, is derived from an analysis of the most volatile-weather-producing regions. It is obtained from a linear index insurance model applied to the extracted singular-decomposed tendencies through SSA on first-component data. The financial risk measure due to weather volatilities serves to predict the future implications of the payouts-in-exceedance in both seasons—wet and dry. The results show that the first PCA component contributes to forty percent of the total variance. The seasonal forecast analysis for the next 24 months shows increasing additional payouts (PO), especially during the wet season. This is caused by the increasing average precipitation tendency component with POERs of 18 and 60 percent in the first and second years. The findings provide important insights into designing agricultural hedging insurance instruments in low-income economies that are reliant on the export of strategic crops, as is the case of Colombian coffee.

Background: A pilot study was performed at a low-income emergency care clinic to assess the humoral immune response to the Johnson & Johnson (J&J) COVID-19 vaccine (Ad26.COV2.S) to better understand how to evaluate the COVID-19 health status of its Hispanic patient population following vaccination. Methods: This study used the Clungene® SARS-CoV-2 IgG/IgM Rapid Test Cassette to determine the presence of binding antibodies resulting from the J&J COVID-19 vaccine. The Clungene test principle is based on the receptor-binding domain (RBD) of the spike protein. Antibodies targeting the spike protein are considered an appropriate measure of humoral response from spike-based vaccines. Results: The study confirmed previous research that antibodies wane over time, and results are consistent with reported vaccine efficacy. There was a statistically significant relationship between the humoral immune response and demographic and health status variables. Conclusions: COVID-19 negative patients can be easily and efficiently monitored to determine the success and durability of COVID-19 vaccines in low-income minority populations. The use of simple low-cost spike targeted COVID-19 antibody lateral flow devices may serve as a useful adjunct to assist community-based physicians on the COVID-19 health status of its patients. Further research is needed to confirm the utility of this approach.

Guilherme Castela,1,2 Joana Providência,1,2 Madalena Monteiro,1 Sónia Silva,3 Manuel Brito,3 Joaquim Neto Murta,1,2 Zélia Correa,4 Miguel Castelo Branco2 1Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; 2Faculty of Medicine, University of Coimbra, Coimbra, Portugal; 3Department of Pediatric Oncology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; 4Bascon Palmer Eye Institute, Miami, FL, USACorrespondence: Guilherme CastelaDepartment of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Avenida Dias da Silva 164, Coimbra, 3000, PortugalEmail gcastela@hotmail.comObjective: The aim of our study was to characterize the evacuated African patients diagnosed with retinoblastoma and referred to the Portuguese national referral center (Centro Hospital e Universitário de Coimbra, University of Coimbra), identifying inequalities in the stage of diagnosis and prognostic results.Design: Retrospective observational study of evacuated African patients diagnosed with retinoblastoma and referred to the Portuguese National Referral Center (Centro Hospital e Universitário de Coimbra, University of Coimbra).Results: The study included 15 patients between October 2015 and October 2020 from Angola, Cape Verde, Guinea-Bissau and São Tomé and Príncipe. Seven (46.7%) children presented bilateral retinoblastoma. The median age at the time of diagnosis was 20.9 (interquartile range, 16– 41) months. The presenting symptoms were leukocoria (86.7%), strabism (53.3%) and buphthalmus (40%). In terms of tumor staging, five (33.3%) children presented with extraocular retinoblastoma and 10 (66.7%) children presented with intraocular retinoblastoma. At presentation, no pineal involvement was diagnosed but two (13.3%) children presented with central nervous system involvement at the time of the first observation. Children were treated with enucleation, exenteration, systemic chemotherapy, intra-arterial chemotherapy and/or supportive palliative care. During the follow-up period (mean 27.2 ± 18.2 months), the overall survival was 73.3%.Conclusion: A small proportion of African children are being referred to our center, when considering the expected incidence of retinoblastoma in these countries, and referred children arrive at advanced stages of the disease, compromising treatment outcomes. Considering retinoblastoma is now a curable disease, national and international interventions are required to attempt a better management of children born in low-income countries.Keywords: retinoblastoma, low income countries, treatment of advanced disease

It is well known that uncertainty and various measures implemented by the government, such as lockdown, social distancing, and travel restrictions during the COVID-19 pandemic, severely impacted low-income households in Bangladesh. This situation forced them to put forward various mechanisms to cope with the devastating situation caused by the pandemic. This paper focuses on the impact of the COVID-19 epidemic on the quality of life (QoL) of low-income households, their survival coping mechanisms, and the impact of the coping mechanisms on their QoL. From 1 October 2021 to 30 December 2021, primary data from 1279 households were collected through online and offline surveys from different divisions of Bangladesh, and were used to analyze the income-generation, transfer, and cost-minimization practices adopted by the households during the pandemic. The Statistical Package for Social Science (SPSS) version 25 was utilized for data analysis. We employed multivariate and regression statistical techniques to achieve the study objectives. The investigation found that QoL declined significantly due to the COVID-19 crisis. The findings also confirmed that coping mechanisms adopted by households varied according to demographic characteristics, and the QoL deteriorated significantly more in those households that adopted more coping mechanisms relative to others, regardless of socio-demographic features. The findings emphasize the importance of recording grounded survey data to track and gather information on the QoL of low-income households during the pandemic, and of constructing evidence-based policy responses. Furthermore, the study contributes to enriching the existing literature on the impact of the corona pandemic, and can serve as a source for potential studies. This study contributes to a clearer picture of the effects of COVID-19 trauma. This survey-based empirical study provides an understanding of the initial micro-level effects of COVID-19 in Bangladesh. This study gives a synopsis of the extent to which Bangladeshi households adopted mechanisms to deal with the COVID-19 crisis and the effects of the adoption of these mechanisms on quality of life.

This study gathered formative data on barriers to optimal child sleep to inform the development of a sleep intervention for parents of preschool-aged children in low-income households. Parents (n = 15, age: 34 ± 8 years, household income: $30,000 ± 17,845/year) reporting difficulties with their child’s sleep participated in this study. Mixed methods included an online survey and semi-structured phone interview. Items assessed barriers/facilitators to optimal child sleep and intervention preferences. Interview transcripts were coded using inductive analyses and constant-comparison methods to generate themes. Derived themes were then mapped onto the Theoretical Domains Framework to contextualize barriers and inform future intervention strategies. Themes that emerged included: stimulating bedtime activities, child behavior challenges, variability in children’s structure, parent work responsibilities, sleep-hindering environment, and parent’s emotional capacity. Parent’s intervention preferences included virtual delivery (preferred by 60% of parents) to reduce barriers and provide flexibility. Mixed preferences were observed for the group (47%) vs. individual (53%) intervention sessions. Parents felt motivated to try new intervention strategies given current frustrations, the potential for tangible results, and knowing others were in a similar situation. Future work will map perceived barriers to behavior change strategies using the Behavior Change Wheel framework to develop a parenting sleep intervention.

BackgroundCaregiver sensitivity is associated with positive child outcomes, and improving sensitivity is often the aim of parenting-directed interventions. However, sensitivity was conceptualized in Western cultures, and its application in populations with different backgrounds is still limited.ObjectiveThis study aimed to foster a contextualized cultural understanding of the meaning and nature of sensitivity by assessing the possibility of evaluating sensitivity in a low-income population living in Ethiopia and describing the nature of (in)sensitive parenting. Moreover, the associations between sensitivity and discipline, the quality of the environment, and individual characteristics were explored.MethodsParental sensitivity was coded on naturalistic video-recorded observations of free interactions between 25 female primary caregivers and their children. Caregivers completed questionnaires on discipline strategies and the level of satisfaction with the environment (access to basic needs, quality of house condition, community and family support, quality of learning opportunities, and working conditions).ResultsThe assessment of sensitivity in this population was possible, with caregivers showing the full range of sensitivity levels. A description of manifestations of sensitivity in this population is provided. A K-means cluster analysis evidenced that high sensitivity was associated with high satisfaction regarding housing conditions and family environment. No association between sensitivity and discipline emerged.ConclusionThe findings show the feasibility of assessing sensitivity in this sample. The descriptions of observed behaviors contribute to understanding culturally specific aspects of sensitivity to consider when assessing sensitivity in similar populations. The study provides considerations and guidelines to inform the structure of culturally-based interventions to promote sensitive parenting in similar cultural and socioeconomic situations.

Low-income informal sector contexts are rife in practices that retain value of materials and goods, but in the academic literature and policy debates these practices are seldom considered as part of the circular economy (CE). This is a major omission in CE discourse, as over 60 percent of the world’s employed population is in the informal sector and many of them make their living from circularity practices. Hence, our paper advances a globally covering understanding of CE by focusing on local practices constituting CE in the overlooked contexts of low-income informal markets of emerging economies, and on the motives behind the practices. To that end we introduce the notion of Necessity-Driven Circular Economy, defined as a set of locally embedded and interlinked formal and informal practices aimed at restoring and retaining the value of goods and materials for as long as possible, based on economic necessity and opportunities for income generation. We substantiate this conceptual work with our empirical findings from low-income urban communities in Brazil, India, and Tanzania. This allows us to capture the essential characteristics of necessity-driven circular economy. These characteristics draw attention to the social and cultural embeddedness and the interweaving of consumption and production in necessity-driven circular economy, as opposed to the dominant techno-economic and industry-focused circular economy conceptualizations that are typical in academic discourse and portray developed country contexts. Finally, we discuss conceptual and practical relevance of necessity-driven circular economy and point out its system-level implications for policymakers and businesses.

Low‐income patients have worse head and neck cancer outcomes than those with high‐income. Yet, few targets have been identified to specifically improve outcomes in the low‐income population. Here, we conduct a review on the current literature on head and neck cancer outcomes in the low‐income population and identify targets for intervention. The degree of disparity is in the range of 20%‐90% worse overall survival in the low‐income population. Eliminating smoking would have the greatest effect on head and neck cancer mortality rates in the low‐income population. Additionally, access to oral cancer exams, assistance with transportation, and continued expansion of telemedicine would facilitate early diagnosis and timely treatment in patients who develop head and neck cancer.

Sharing of sanitation is common in low-income settlements in Sub-Saharan Africa. However, shared (limited) sanitation facilities have been thought to pose health risks due to poor hygiene levels. Interventions to improve user behavior and cleanliness of shared sanitation are few, both in literature and in practice. This study details the codesign and testing of strategies to improve the cleanliness of shared sanitation facilities in low-income areas of Kisumu City in Kenya. The strategies included a cleaning plan, monitoring system, and discussions among users, and were codesigned through workshops with stakeholders and group discussions with landlords and tenants. These strategies were tested in 38 compound houses through the Trials of Improved Practices approach over a 5-month period. Field staff visited the compounds, observed the cleanliness of the shared toilets, and through discussions, encouraged users to develop a formal cleaning system and a monitoring plan. The discussions built social capital and collective action and facilitated uptake of the cleaning plan with notable improvements in cleanliness of shared toilets. The results support the acceptability of shared sanitation in low-income settlements, the importance of codesigning and coproducing solutions with users, and the need to evaluate the effects of these strategies on cleanliness of shared sanitation.

Purpose: The maternal mortality ratio for the United States (US) has consistently risen over recent decades. This mortality is especially pronounced within minority populations who experience a maternal mortality and morbidity rate that are much higher than their non-Hispanic white counterparts. Qualitative data are critical in gaining true insight from minority pregnant and postpartum persons. Such data should serve as the basis for building interventions and programs that seek to eradicate perinatal inequities. This review examines the qualitative literature on racial and ethnic minority pregnant patients with low income and their experiences during perinatal care (PNC) to identify recurrent themes that can be addressed through targeted interventions. Methods: PubMed, CINAHL, and Web of Science databases were searched for qualitative studies on racial and ethnic minority pregnant patients with low income and their experiences during PNC. Twenty-two articles were included for analysis. Thematic synthesis was performed to identify categories and recurring themes in each article. Results: Five major categories were identified as consistent experiences of pregnant patients with PNC clinicians: support, education, connection, communication, and trust. Of these, clinician support was the most consistently coded category. Eighteen of the 23 articles discussed tangible support patients had received from their clinicians, such as care coordination and referrals to support services. The second most coded category was education, which was represented in 16 articles. Education was mostly represented negatively as lack of adequate perinatal care education given during the perinatal period. Finally, the categories of connection, communication, and trust were represented by 18, 17, and 17 articles, respectively. Conclusions: These qualitative studies provided specific examples of what racial and ethnic minority pregnant patients with low income deemed positive and negative during the perinatal period and outline ways that these experiences can be improved. Future studies can take the experiences reported in this review to help inform interventions to improve patient experiences and health outcomes that minority persons face in the perinatal period.

Cement is an important construction material in concrete production; however, it is expensive and unaffordable for many low-income and rural communities in developing countries. Rice husk is a by-product from the rice mill process, with an approximate ratio of 200 kg rice husk per one tonne of rice produced. This experimental study aimed to investigate the integrity of concrete produced in Zambia using rice husk ash (RHA) to partially replace cement. The primary goal was to carry out a cost–benefit analysis on the use of RHA in concrete. RHA was used to partially replace cement with ratios of 10 %, 20 % and 30 %. The 20 % cement replacement mix produced the optimum 18 MPa concrete strength results at a 0.5 water/binder ratio. This translated in cost reduction of concrete by 12.5 %, which is particularly significant for higher concrete volumes. The produced concrete is suitable for lightly loaded structures, such as foundation footings, surface beds and walkways to benefit low-income communities. The study further concluded that the RHA based concrete was more cost-efficient in structures that were close to areas of rice production due to reduced RHA transportation costs.

Perception and knowledge of risk factors for pregnancy influence health behaviors during pregnancy and childbirth. We used a descriptive qualitative study to examine the perception and knowledge of risk factors in pregnancy and childbirth in low-income urban women in Ghana. Over the course of three-months, 12 focus group discussions and six individual interviews were conducted with 90 participants selected from six communities in the study area. Data were analyzed using inductive-thematic content analysis. Findings revealed that participants had knowledge of some risk factors, although some had superstitious beliefs. Participants viewed pregnancy as an exciting and unique experience, but also challenging, with a host of medical and psychological risks. Pre-existing medical conditions (e.g., diabetes), lack of physical activity, poverty, poor nutrition, and lack of social support were identified as conditions that could lead to negative pregnancy outcomes. Superstitious beliefs such as exposure to “evil eye” during pregnancy, as well as curses and spells, were also identified as risk factors for pregnancy complications. This research has implications for policies and programs to improve pregnancy outcomes for low-income women in Ghana. Thus, we recommend social and economic support programs as well as health education to change misperceptions about pregnancy risk and to support other efforts being made to improve maternal health outcomes.

Despite the many benefits of club-organized sports participation for children, studies have shown that sports participation is lower among children from low-income families than among children from middle- or high-income families. Adopting a socioecological perspective, the main aim of our study was to identify and describe experiences of person-environment (PE) misfits in relation to parental facilitation of children's sports participation. We conducted 24 interviews with parents from low-income families. PE misfits were found in multiple behaviors related to the facilitation of children's sports participation: financing sports participation; planning and investing time; transporting children; acquiring, processing, and providing information; and arranging support. Across these PE misfits, influential attributes were found on the individual level (e.g., skills) as well as within the social, policy, physical, and information environment. In response to PE misfits experienced, parents deployed multiple strategies to reduce these PE misfits, aimed at enhancing either themselves (e.g., increasing financial capacities) or their environments (e.g., arranging social support). These results provide an insight into experienced PE misfits that took the form of multiple specific behaviors which parents found difficult while facilitating their children's sports participation. Furthermore, the results provide insight into the environmental and individual attributes that were involved in these PE misfits, and into how parents modified themselves or their environments in order to make their environments more supportive. The study contributes to future research on individual and environmental influences on parental facilitation of their children's sports participation, as well as on the development of multilevel interventions aimed at increasing sports participation among children from low-income families.

Despite the many benefits of club-organized sports participation for children, studies have shown that sports participation is lower among children from low-income families than among children from middle- or high-income families. Adopting a socioecological perspective, the main aim of our study was to identify and describe experiences of person–environment (PE) misfits in relation to parental facilitation of children’s sports participation. We conducted 24 interviews with parents from low-income families. PE misfits were found in multiple behaviors related to the facilitation of children’s sports participation: financing sports participation; planning and investing time; transporting children; acquiring, processing, and providing information; and arranging support. Across these PE misfits, influential attributes were found on the individual level (e.g., skills) as well as within the social, policy, physical, and information environment. In response to PE misfits experienced, parents deployed multiple strategies to reduce these PE misfits, aimed at enhancing either themselves (e.g., increasing financial capacities) or their environments (e.g., arranging social support). These results provide an insight into experienced PE misfits that took the form of multiple specific behaviors which parents found difficult while facilitating their children’s sports participation. Furthermore, the results provide insight into the environmental and individual attributes that were involved in these PE misfits, and into how parents modified themselves or their environments in order to make their environments more supportive. The study contributes to future research on individual and environmental influences on parental facilitation of their children’s sports participation, as well as on the development of multilevel interventions aimed at increasing sports participation among children from low-income families.

This study presents a pilot study in suburban households in Salvador, Brazil, inserted in the context of a framework developed to aid water demand management strategies. The framework aims to understand the barrier of subjectivity while identifying consumption habit patterns in households. Six key sets of components create the framework architecture: (1) characterization of the area based on: context, climate, population/area, population growth rate, and water management challenges; (2) a survey to obtain socio-demographic and physical property data of the sample; (3) smart metering and data processing systems to monitor sample water end use; (4) determining daily consumption patterns; (5) analyzing qualitative data through theoretical consumption models to identify relevant variables for the next step; and (6) construction of representative mathematical models of consumption for each daily practice (this item was not included on pilot). It provides a starting point to understand how water demand management strategies can be supported at the user and decision-making level. As a result, improvements to the interview guides used in the pilot were suggested. Furthermore, customized measures to promote rational water consumption were identified in the study area, and policies could be proposed.

Adolescents living in low-income areas often have high need for mental health supports due to experiences of poverty and trauma, coupled with limited access and availability of such supports. This study investigated the implementation of a socio-emotional learning curriculum titled, “Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A),” which was integrated into health classes in a low-income high school. While preliminary evidence suggests that DBT STEPS-A can be effective in reducing mental health symptoms in high school students, this study is the first to explore the program’s acceptability, appropriateness, and feasibility when implemented in a low-income school. The implementation presented here also diverged from recommended training protocols due to time and cost limitations. Quantitative and qualitative data were collected from 29 school stakeholders prior to implementation and from 23 school stakeholders post-implementation. Our results indicate that DBT STEPS-A is acceptable and feasible for teachers involved in offering the program and that more work is needed to address appropriateness of the content for racially and socio-economically diverse students, ease of implementing lessons, and support for teachers using DBT STEPS-A skills outside of class. We conclude with a discussion of key implementation challenges and solutions generated.

Integration of digitalization and automation with logistics systems promotes effective and efficient flow of goods, information, and services, contributing to economic development. The level of implementation of digitalization and automation in low-income countries is still low, however. The aim of this study is to establish which digitalized logistics practices could best be adopted by firms in low-income countries. A systematic literature review was used to identify state-of-the-art digitalization and automation technologies in logistics chains. Criteria for adopting digitalized logistics practices were also identified in the literature review. An expert survey was conducted to identify criteria weights using analytical hierarchy process (AHP). Economic benefit, infrastructure, and affordability were the criteria that were given the highest weights by the experts. Case studies that applied state-of-the-art technologies such as internet of things (IoT), radio frequency identification (RFID), blockchain, big data analytics (BDA), and sensors mainly for traceability, production operation, and warehouse and inventory management were considered as recommended practices. Identification of suitable practices considering the local conditions in low-income countries could help logistics professionals and policymakers adopt enabling technologies in logistics chains.

Introduction Tobacco disparities persist among low-income smokers who seek care from safety-net clinics. Many of these patients suffer from chronic illnesses (CILs) that are associated with and exacerbated by smoking. The objective of the current study was to examine the differences between safety-net patients with and without CILs in terms of nicotine dependence and related factors (such as depression, anxiety) and self-efficacy regarding ability to abstain from smoking. Methods Sixty-four low-income smokers who thought about or intended to quit smoking were recruited from the San Francisco Health Network (SFHN) and assessed for CILs, nicotine dependence, depression, anxiety, and smoking abstinence self-efficacy. Four one-way analyses of variance were used to examine the difference between those with and without CIL on the latter four variables. Results The CIL group had significantly higher anxiety (CIL: 8.0 ± 5.35; non-CIL: 4.44 ± 3.48; p=0.02) and tended to have higher nicotine dependence (CIL: 5.40 ± 2.58; non-CIL: 3.88 ± 2.28; p=0.04). In the CIL group, nicotine dependence was positively correlated with anxiety [r(62)=0.39; p

Background Breast cancer is the most common cancer diagnosed in women. Screening mammography is the only imaging screening study for breast cancer with a proven. mortality benefit. This study aims to analyze the cost-effectiveness of screening mammography in Ethiopia. Methods Multistate Markov model was used for computer simulation to estimate cost and health benefits of screening mammography interventions for age-group of 40–49 years and 50–59 years. The cost-effectiveness analysis was made for 4 policies based on where the screening mammography procedures were conducted: government institution only, the private institution only, 50% ratio for each, and 10% private institution policy. Outputs were expressed in total cost, life-years gained (LYG) incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INMB). Results All 4 policies of annual screening mammography failed to achieve acceptable ICER and lead to a net loss in INMB. The lowest ICER value was for government institution-only policy with 3510.3 USD/LYG and 3224.9 USD/LYG both above the cost-effectiveness threshold of 2808.5 USD. The cost per single death averted for each group was 110,206.7 USD and 77,088.2 USD for age-group 40–49 years and 50–59 years respectively. Conclusion Screening mammography could not be shown to be cost-effective in Ethiopia with the current low cost-effectiveness threshold. Alternative screening approach like annual clinical breast examination may need to be investigated.

Background: The treatment gap for bipolar disorder is aggravated by economic inequality. Around half of the world's population live in a low-or lower-middle-income country, where research on treatment is scarce. Hence, this review aims to determine the number and types of intervention studies conducted on adults with bipolar disorder in low-income and lower-middle-income countries and analyze the effect of these interventions on symptom severity, medical adherence, and quality of life. Methods: A systematic review was conducted in June and November 2021 using eight databases. Controlled intervention trials on adults with bipolar disorder on data from low-income and lower-middle-income countries at time of publication were included. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or The Risk Of Bias In Non-randomized Studies of Interventions assessment tool. Results: Twenty-one studies met the inclusion criteria. These were divided into four subtypes based on the intervention; pharmacotherapy (=12), psychosocial (=7), electroconvulsive therapy (=1), and traditional medicine (=1). Three studies were from low-income countries. A high risk of bias characterized the studies; only four studies reported the procedures used for randomization. Most studies, however, identified a beneficial effect on symptom severity, and in addition, medical adherence could be improved with psychosocial interventions. Limitations: Heterogeneity across studies prevented any meaningful pooling of data to meta-analyses. Conclusion: Data for treatment interventions contextualized to the local setting for bipolar disorder remains sparse, particularly from low-resource settings. Further studies are urgently needed to target the treatment gap for bipolar disorder. Trial registration: PROSPERO: CRD42020170953.

Problems in the public policy decision-making environments are typically complex and continuously evolve. In a resource-constrained environment, several alternatives, criteria, and conflicting objectives must be considered. As a result, solutions to these types of problems cannot be modelled solely using single-criteria techniques. It has been observed that most techniques used to shape energy policy and planning either produce sub-optimal solutions or use strong assumptions about the preferences of decision-maker(s). This difficulty creates a compelling need to develop novel techniques that can handle several alternatives, multiple criteria and conflicting objectives to support public sector decision-making processes. First, the study presents a novel scenario-based multi-objective optimisation framework based on the augmented Chebychev goal programming (GP) technique linked to a value function for analysing a decision environment underlying energy choice among low-income households in isolated rural areas and informal urban settlements in South Africa. The framework developed includes a multi-objective optimisation technique that produced an approximation of a Pareto front linked to an a priori aggregation function and a value function to select the best alternatives. Second, the study used this model to demonstrate the benefits of applying the framework to a previously unknown subject in public policy: a dynamic multi-technology decision problem under uncertainty involving multiple stakeholders and conflicting objectives. The results obtained suggest that while it is cost-optimal to pursue electrification in conjunction with other short-term augmentation solutions to meet South Africa's universal electrification target, sustainable energy access rates among low-income households can be achieved by increasing the share of clean energy generation technologies in the energy mix. This study, therefore, challenges the South African government's position on pro-poor energy policies and an emphasis on grid-based electrification to increase energy access. Instead, the study calls for a portfolio-based intervention. The study advances interventions based on micro-grid electrification made up of solar photovoltaics (PV), solar with storage, combined cycle gas turbine (CCGT) and wind technologies combined with either bioethanol fuel or liquid petroleum gas (LPG). The study has demonstrated that the framework developed can benefit public sector decision-makers in providing a balanced regime of technical, financial, social, environmental, public health, political and economic aspects in the decision-making process for planning energy supply interventions for low-income households. The framework can be adapted to a wide range of energy access combinatorial problems and in countries grappling with similar energy access challenges.

Financial literacy contributes to the economic well-being of every country. Specifically, the financial literacy level of low-income households is crucial in the process of developing and building economic potential. Moreover, the knowledge, attitude, and behavior of families are essential to the financial sustainability and money-wise behavior of low-income households. Thus, financial literacy and financial well-being are vital for low-income households to survive in highly competitive marketplaces and sustain their socioeconomic status. This study intends to examine the impact of financial literacy on the socioeconomic status of low-income households. A self-administered survey questionnaire was employed, and the sample consists of 282 randomly selected respondents from low-income households in Malaysia. The data were analyzed using the Structural Equation Modelling procedure in IBM-SPSS-AMOS 26.0 to examine the causal effect. The results showed that financial literacy (consisting of financial knowledge, financial behavior, and financial attitudes) has a positive and significant impact on the socioeconomic status of low-income households. Moreover, financial well-being also mediated the effect of financial literacy on socioeconomic status. The research results provide new ideas and perspectives for improving money-wise mechanisms and the socioeconomic sustainability of low-income households.

This paper investigates the determinants of loyalty for low income earners in emerging markets. A survey of 287 customers of specialized banks (banks built for low income earners) in Abakaliki Nigeria was conducted. The hypotheses under study were tested using factor and regression analysis. The results from the test show that determinants of customer loyalty include satisfaction, trust as well as perceived service quality. However, corporate image is not a determinant of customer loyalty. This study offers important implications to researchers as well as practitioners and highlights the insignificance of the company’s image to customer loyalty which is a basis for further studies. In the Nigerian societal context, corporate social responsibility (CSR) which in turn gives rise to corporate image is viewed as an act of philanthropy and mostly carried out by most multi-national companies (MNCs). The CSR programmes of these Multi-nationals mimic the CSR programmes of western economies neglecting local realities and the peculiarities of the Nigerian diverse economy occasioned by socio-economic challenges.

Daily oral pre-exposure prophylaxis (PrEP) is a key tool in addressing high HIV incidence among young women, and breaking the cycle of transmission. From 2017 to 2020, Médecins Sans Frontières (MSF) offered PrEP, in conjunction with contraception and risk-reduction counselling, to women aged 18–25, in a government-run clinic in Khayelitsha, a low income high HIV prevalence area in South Africa. Drawing on clinical, quantitative, and qualitative interview data, we describe participants’ experiences and engagement with the PrEP program, participant adherence (measured by TFV-DP levels in dried blood spots) over time, and the indirect benefits of the PrEP program. Of 224 screened and eligible participants, 164 (73.2%) initiated PrEP, with no large differences between those who initiated and those who did not. Overall, 47 (29%) completed 18 months follow-up, with 15 (9.1%) attending all visits. 76 (46.9%) participants were lost to follow-up, 15 (9.1%) exited when leaving the area, and 28.7% of exits happened in the first month of the study. We identified two different trajectories of PrEP adherence: 67% of participants had, on average, consistently low TFV-DP levels, with the remaining 33% having sustained high adherence. Few baseline characteristics predicted good adherence. The main reported barrier to taking PrEP was forgetting to take or travel with the pills. Encouragement from others declined as a reported facilitator from month 6 to 18 (family: 93.1% vs 77.6%, p = 0.016, friends: 77.6% vs 41.4%, p ≤ 0.001, partners: 62.1% vs 46.6%, p = 0.096, other PrEP users: 89.7% vs 74.1%, p = 0.020). Disclosure to friends and family in some cases opened dialogue around sex, and helped to educate others about PrEP. Self-reported sex with more than one partner, and sex without a condom, decreased significantly after enrolment (p

The industrial policy literature has made important contributions to understanding how to catalyze industrialization, but it tends to focus more on the industrial policies required to incentivize learning than on studying firm-level learning dynamics and investments in technological capabilities. Furthermore, global value chain studies on export sectors in low-income countries rarely consider whether local firms are part of broader business groups and if so, how that position within business groups affects local firms’ business strategies regarding the global supply chain in question as well as investments outside it. This article examines local firms’ investments in a new export industry, and they are shaped by dynamics linked to their family business groups, industrial policies, and the wider national economic and political contexts of low-income countries. It does so through a case study of Ethiopia and the emergence of its floriculture export industry. The article explains firm-level motivations in acquiring knowledge and building capabilities as well as their export trajectories and firm growth paths and how they are shaped by owners’ decisions related to the overall business group. It argues that industrial policies need to consider not only the existing capabilities, organizations, and networks of local firms but also tailor industrial policies to the potential of the family business groups to drive capability building in new industries.

Performance evaluation in logistics is crucial in identifying improvement opportunities. This study assessed performance indicators (PIs) for import–export logistics chains, including transport, dry ports, transhipment and warehouses, focusing on Ethiopia. PIs were identified by means of a literature review. An expert survey based on the analytical hierarchy process (AHP) was used to obtain weightings for the indicators to allow an evaluation of the overall performance of the country’s import–export chains. Key challenges faced in the sector were also identified. Indicators such as turnaround time and damage frequency were given high weightings by experts for dry port PIs, security was given the highest weighting for transport PIs, and order lead time was given the highest weighting for warehouse PIs. Technological advancements, human resource capacity building and government policies were found to be the main areas that could improve the performance of logistics operations and address the challenges faced by the sector. These findings could provide a new and comprehensive picture of the key performance indicators of Ethiopian import–export logistics chains.

Purpose: Weight stigma has become widespread within health care and disproportionately affects women, who are under greater appearance-based scrutiny than men. It is also well established that rural-based individuals with low incomes suffer greater health disparities compared with urban, higher-income counterparts, yet studies examining recommendations for nonstigmatizing health care among higher-weight women from low-income rural settings are lacking. This study examined the experiences and recommendations of higher-weight, low-income, rural women, with the aim of improving health care for similar populations. Methods: In-depth, semi-structured interviews were conducted in a rural region of the Midwestern United States to explore participants’ recommendations for redressing stigma within health care. All participants (n = 25) self-identified as higher-weight, low-income, rural women. Results: All participants experienced or were aware of weight stigma within health care. Themes identified from responses were understanding patients and their situations, offering options and supplemental information, communicating effectively, taking time, and having a positive attitude. Patient recommendations focused on correcting physician biases, rapport-building, and providing holistic care. Conclusions: The findings suggest that weight stigma is prevalent within health care provided to low-income women in rural U.S. Midwest and that there are specific communication and training approaches that may reduce the prevalence of weight stigma in health care.

Introduction: Tobacco is the only legal product that kills a large proportion of its consumers when used as intended by its manufacturer. The effect of nicotine as a driving substance on smoking has been established for decades. Still, very little is known on how the biopsychosocial determinants relationship affects levels of nicotine addiction in smokers, especially in the urban low-income population. The study aimed to validate measurement scales related to biopsychosocial factors that will be used in the future study to evaluate biopsychosocial components that influence nicotine addiction among urban poor smokers. Methods: Exploratory factor analysis (EFA) using the principal component analysis with varimax rotation and Kaiser normalization was used to assess the factor structure. Then, the confirmatory factor analysis (CFA) was conducted to assess the unidimensionality, validity, and reliability of the latent construct. Results: EFA showed extraction of factors according to their original scales with all factor loading and communality's values were above 0.5. During CFA, factor loading less than 0.6 was deleted. Convergent validity verified by computing the Average Variance Extracted (AVE) for every construct range between 0.528 – 0.801. The Fitness Indexes achieved the required level (RMSEA=0.05, CFI=0.937, Chisq/df=1.7). Meanwhile, the Discriminant Validity Index range between 0.75-0.89, which is higher than the correlation coefficient value. Internal consistency assessed from Composite Reliability range between 0.714-0.965. Conclusion: The measurement scales are valid and reliable to assess the intended constructs among low-income male smokers in the urban area.

Efforts to empower the poor communities in urban areas are still very urgent at this time. Although the number of poor communities in urban areas is decreasing, the rate is not significant. Empowerment needs to place poor urban as the main actors and the government as facilitators and motivators. This research aims to provide a scientific description of the causes of poverty and the empowerment model for the poor urban in Makassar city, South Sulawesi Province, Indonesia. The research method used is qualitative with a narrative strategy. The research participantswere as many as five low-income households in an urban area. The data collection technique used in-depth interviews with participants. Field observations were also made related to participants' social life and literature studies to strengthen the interview and observation data. Data analysis takes three ways: data reduction, data display, and verification/conclusion drawing. The result showed three factors that cause urban poverty: natural, cultural, and structural. The empowerment model was implemented by understanding theproblems encountered, developing problem-solving strategies, understanding the importance of making planned changes, and strengthening the urban poor's capacity. Keywords:Empowerment Model; Economic Development; Human Development; Low-Income; Urban Poverty Society

Despite increasing policy emphasis on creating a more equitable society as a key component of the energy transition, there is still a dearth of assessments investigating the equity outcomes of decarbonisation scenarios and community scale Just Transition case studies, and those focusing on both energy and transport. This work seeks to fill this gap by examining energy and transport poverty could be alleviated by scenario analysis of these linked aspects of the Just Transition using an urban and a rural case study in Northern Ireland. This work examines the total costs of ownership of mode shifting and car sharing in transport and investment needs for domestic retrofit for energy poverty alleviation. The analysis finds that eBikes for suitable commutes bring substantial economic and environmental benefits compared to cars. For car sharing, the economic and environmental benefits are also substantial, with electric vehicles becoming cost effective at all occupancy rates from 2025. Regarding the alleviation of energy poverty, the mean cost to retrofit energy poor dwellings ranges from £2,143 depending on dwelling type. However, up to 3.5% of residents of each dwelling type will find the consequent debt burden causes significant financial stress, particularly for the elderly and those claiming benefits. This study concludes that the current mechanisms to support energy and transport poverty alleviation are insufficient and too narrowly targeted. Their expansion is a requisite component of any hopes of achieving a Just Transition in Northern Ireland.

Shifting environmental conditions and poor or insufficient hygiene facilitates the transmission of bacteria and viruses between and within species of animals; between humans; and between humans and animals. Taking a One Health perspective, we used interviews to explore with 20 women living on low income in Kenya: their gendered hygiene practices and daily contact with animals; how and why they access water and sanitation facilities for themselves, their families, and any livestock; and their understandings of (zoonotic) health risks and disease transmission within their local environments. The women described how they worked every day to keep bodies and homes clean by washing bodies, surfaces and clothes. Women's hygiene practices focussed on removing visible dirt partly because of concerns for health but also to support their families' social standing in their community. While they were less aware of any 'invisible' risks to health through contact with animals or other hazards present in their daily living environments, most exercised care to source and manage water for drinking. Contaminated water was recognised as a risk to health suggesting that in this case, women accepted that there were 'invisible risks' to health, even in clear water, and took steps to mitigate them.

Objectives To assess hypertension prevalence and the extent and associated factors of hypertension diagnosis, follow‐up, treatment and control gaps in low‐income urban Medellin, Colombia. Methods We randomly sampled 1873 adults aged 35 or older. Unaware hypertensive individuals were defined as those without previous diagnosis whose average blood pressure was equal to or above 140/90 mmHg. For aware hypertensive patients, control was delimited as average blood pressure below 140/90 if under 59 years old or diabetic, and as less than 150/90 otherwise. We used logistic regression to identify care gap‐associated factors. Results Hypertension prevalence was 43.5% (95% CI 41.2–45.7). We found 28.2% aware and 15.3% unaware hypertensive individuals, which corresponds to a 35.1% (95% CI 31.9–38.5) underdiagnosis. This gap was determined by age, sex, education and lifestyle factors. 14.4% (95% CI 11.6–17.6) of aware hypertensive patients presented a follow‐up gap, 93.4% (95% CI 90.9–95.2) were prescribed antihypertensive drugs, but 38.9% (95% CI 34.7–43.3) were not compliant. The latter was strongly associated with follow‐up. The hypertension control gap in aware hypertensive patients, 39.0% (95% CI: 34.9–43.2), was associated with being older, having diabetes, weakly adhering to pharmacological treatment and receiving poor non‐pharmacological advice. Overall, 60.4% (95% CI 57.0–63.8) of aware and unaware hypertensive participants had either diagnosed but uncontrolled or undiagnosed hypertension. Conclusions We found high hypertension prevalence coupled with, from an international perspective, encouraging awareness and control figures. Still, there remains ample room for improvement. Our findings can assist in designing integrated primary healthcare measures that further strengthen equitable and effective access to hypertension care and control.

Background Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices. Methods We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016–Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions. Findings Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia. Interpretation Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance. Funding Wellcome Trust and Volkswagen Foundation.

This paper examines the orientations to the future of young people living in low-income families in the U.K. and Portugal following the 2008 Global Financial Crisis and the contexts in which they are socially reproduced. It is based on data from comparative research on families and food poverty, funded by the European Research Council. The study focused on parents and young people aged 11–16 living in low-income families in three European countries (the U.K., Portugal and Norway); only the U.K. and Portuguese data were analysed here. Given the study was concerned with the consequences of low income for food insecurity, we primarily sought to understand how young people manage in the present; however, the project also affords a theoretical and methodological opportunity to explore young people’s thoughts about the future as they begin to transition to adulthood. We found that, when asked about the future, young people responded in different ways: some said they did not think about the future; others mentioned their dreams, but considered them unrealisable. while others expressed hopes that were more concrete and achievable. Precarity constrained the control that young people and their families exercised over their lives. We argue that young people’s aspirations and time horizons are framed in relation to the present and the temporalities of the life course, the public discourses to which they are subjected and the limited access of their families to resources provided by the labour market and the state.

Cycling is a convenient, and affordable mode of active transportation linked to increased physical and mental health, as well as environmental and socioeconomic benefits. However, cycling represents a marginal mode of commuter transportation in Canada, undertaken primarily by men with high levels of income and education. The factors that deter women in low-income neighbourhoods from engaging in utilitarian cycling are poorly understood. This study employs parametric modeling software Grasshopper to develop an analytical tool capable of generation optimized cycling route recommendations, based on input parameters hypothesized to encourage greater female ridership. To evaluate the parameters, the analytical tool is used to connect a residential low-income neighbourhood in Guelph to utilitarian destinations such as grocery stores, schools, childcare services, and existing cycling networks. The results indicate that more direct routes, greater separation from vehicular traffic, and lower speed limits are required to encourage equitable access to utilitarian cycling.

Background: COVID-19 has spread across the globe, resulting in significant changes in virtually every aspect of life. Mitigation efforts, like shelter-in-place orders, have taken a particular toll on parents who have had to navigate disruptions in work and/or school schedules. Research from high-income countries demonstrates increased parental anxiety, stress, depression, and burnout resulting from the pandemic. It is unclear if these outcomes are the same for parents in high-risk communities in low-income countries where pre-pandemic conditions were deleterious. This study addresses this gap and examines the mental health impact of the pandemic on parents in high-risk communities in Guatemala. Methods: A total of 330 individuals from 11 districts in Guatemala participated in the study and were assessed for sociodemographic characteristics and mental health impairment. Chi-squares were conducted for bivariate analysis. Multivariate analysis was conducted using binary logistic regression. Results: Bivariate analysis revealed differences between groups on burnout, with parents more often reporting feelings of burnout than nonparents ( p Conclusion: Our findings underscore the importance of identifying the unique mental health impact of the COVID 19 pandemic on parents in high-risk communities. In high-risk communities, parental stress is a pressing problem that, if unaddressed, has the potential to result in even greater psychological distress and child maltreatment. Training community healthcare providers to assess and address parental stress can lead to increased community capacity and the development of a community-based network to serve as a first line of support for parents and their children.

Interest is high on the World Bank’s role in and use of the Low-Income Country Debt Sustainability Framework (LIC-DSF) in light of the sharp rise in debt stress among low-income countries and a changing global risk landscape in the years leading up to and resulting from the coronavirus pandemic (COVID-19). Since 2015, the number of IDA-eligible countries at high risk of or in debt distress has more than doubled. As the key instrument to assess the debt sustainability of IDA eligible countries, the LIC-DSF is intended to guide the World Bank’s advice and support to these countries. This evaluation seeks to assess how the World Bank contributes to the LIC-DSF, how it uses LIC-DSF output in various corporate and country-level decisions, and how it can better leverage the LIC-DSF to address debt vulnerabilities in LICs. In doing so, it will seek to identify opportunities for the World Bank to strengthen its role in the preparation and use of the LIC-DSF in a changing global context and to highlight potentially important questions that may need to be addressed in the upcoming joint review, including the extent to which the LIC-DSF meets IDA’s needs in serving its clients. Recommendations from this evaluation will focus on aspects of the LIC-DSF that are within the World Bank’s ability to change or influence.

Recent South African and international evidence highlights the broad and lasting impacts of households, particularly those on low income, when unable to afford higher income counterparts to live in apartments, maintained public housing, and other high-quality houses. A broad range of lowincome houses recently built in South African local municipalities are reportedly defective, due to poor building and construction quality. This study aims to assess and determine the factors influencing highquality housing positively impacting on the lives of a significant proportion of low-income housing projects. Reasons for and obstacles to quality design, construction quality and the development of low-income housing projects were identified. To assess the research questions, a quantitative survey (n=103) was carried out, simple random and purposive sampling techniques were used to select contractors who were active in low-income housing projects within the Polokwane Municipality. The quantitative data gathered were analysed using Statistical Package for the Social Sciences (SPSS) to determine a combination of descriptive and nonparametric statistics of the data computing the frequencies, mean scores and standard deviations. Selected results show that poor-quality and low-income housing projects are perceived to be related to the contractors, builders and construction practitioners not complying with the standards, variously because of insufficient training or accountability to public authorities and end users of low-income houses, i.e., the beneficiaries. The respondents were of the view that house builders and local government authorities could use five factors, namely quality standards, management, involvement of people, process design and process, planning and scheduling to assess non-conformance to quality requirements in low-income housing projects in South Africa. The finding of this study provides a platform for improving the quality of housing design, construction projects, sustainability and an opportunity for local and international design and construction professionals to rethink design in the context of low-income housing projects. Onlangse Suid-Afrikaanse en internasionale bewyse beklemtoon die breë en blywende impak van huishoudings, veral dié op lae inkomste, wanneer hulle nie in staat is om hoër-inkomste eweknieë te kan bekostig, in woonstelle te woon, openbare behuising te onderhou of in ander hoë-gehalte huise te kan woon nie. ’n Wye reeks laeinkomstehuise wat onlangs in Suid-Afrikaanse plaaslike munisipaliteite gebou is, is glo gebrekkig, wat verband hou met swak bou- en konstruksiegehalte. Die doel van hierdie studie is om die faktore wat hoë kwaliteit behuising beïnvloed wat ’n positiewe impak het op die lewens van ’n beduidende deel van lae-inkomstebehuisingsprojekte te bepaal. Redes en struikelblokke vir kwaliteitontwerp, konstruksiekwaliteit en die ontwikkeling van lae-inkomstebehuisingsprojekte is geïdentifiseer. Om die navorsingsvrae te assesseer, is ’n kwantitatiewe opname (n=103) uitgevoer, eenvoudige ewekansige en doelgerigte steekproeftegnieke is gebruik om kontrakteurs te kies wat aktief is in lae-inkomstebehuisingsprojekte binne Polokwane Munisipaliteit. Die kwantitatiewe data wat ingesamel is, is ontleed deur gebruik te maak van Statistiese Pakket vir die Sosiale Wetenskappe (SPSS) om ’n kombinasie van beskrywende en nieparametriese statistieke van die data te bepaal wat die frekwensies, gemiddelde tellings en standaardafwykings bereken. Resultate het getoon dat behuising en lae-inkomstebehuisingsprojekte van swak gehalte beskou word as verwant aan die kontrakteurs, bouers en konstruksiepraktisyns wat nie aan die standaarde voldoen nie, en hulle verskil vanweë onvoldoende opleiding of aanspreeklikheid teenoor openbare owerhede en eindgebruikers van lae-inkomstehuise, dit wil sê die begunstigdes. Die respondente was van mening dat huisbouers en plaaslike regeringsowerhede vyf faktore, naamlik gehaltestandaarde, bestuur, betrokkenheid van mense, prosesontwerp en proses, beplanning en skedulering kan gebruik om die nie-nakoming aan gehaltevereistes in lae-inkomstebehuisingsprojekte in Suid-Afrika te meet. Die bevinding van hierdie studie bied ’n platform vir die verbetering van kwaliteit van behuisingsontwerp, konstruksieprojekte, volhoubaarheid en ’n geleentheid vir plaaslike en internasionale ontwerp- en konstruksiekundiges om ontwerp in die konteks van laeinkomstebehuisingsprojekte te heroorweeg.