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Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)—a national sanitation program initiated in 2014—and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011–2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000–70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Purpose: Indian states at greater levels of economic development report more suicides. This relation appears stronger among women relative to men. We test the hypothesis, suggested in the literature, that conflict between rapid economic growth and inadequate female autonomy (approximated using total fertility rate) varies positively with female suicides. Methods: We used state-level data on female suicides for all 35 Indian states and union territories, from 2001 to 2011, from the National Crime Records Bureau. We specified, as our outcome, age-adjusted female suicides per 100,000 population per state-year. We retrieved data on key covariates, namely, gross state domestic product (GSDP) per capita, total fertility rate (TFR), and other control variables from multiple national surveys and publicly available data sources. We examined whether and to what extent age-adjusted female suicides (per 100,000 population) correspond with total fertility rate (lower TFR indicates greater female autonomy and vice versa) within the context of greater economic development (GSDP per capita). Linear longitudinal mixed effect regressions controlled for state-specific random intercepts, son preference (male:female sex ratio at birth), literacy gap (percentage difference between literate males and females), access to health systems (institutional deliveries), female to male employment ratio, and linear time trends. Results: At constant levels of GSDP per capita, a one unit decline in TFR corresponds with 0.27 fewer female suicides per 100,000 population (P value = 0.008). Sensitivity tests indicate that this relation does not hold for male age-adjusted suicides (per 100,000 population). Conclusion: Our findings, if replicated, indicate that at constant levels of economic development, lower TFR (indicating greater female autonomy) may reduce suicide risk among women. [ABSTRACT FROM AUTHOR]

We examined whether county-level increases in continuity of mental health care (i.e., mental health visits per mental health patient) at Community Health Centers (CHCs) correspond with a decline in Emergency Department (ED) visits for suicidal ideation and self-harm (1) overall, and (2) among specific race/ethnicities across 211 counties from 10 US states, from 2006 to 2015 (sample size = 1412 county-years). We used fixed effects linear regression analyses with county-level socioeconomic covariates and year indicators. In the full sample, continuity of mental health care at CHCs varies inversely with ED visits for suicidal ideation/self-harm (coefficient: −0.04, p < 0.1). Race-specific analyses show that a one unit increase in continuity of mental health care at CHCs corresponds with a 5% decline in ED visits for suicidal ideation/self-harm among whites (p < 0.05). Expansion of mental health care services at CHCs may serve as a key point of prevention for suicidal behavior. [ABSTRACT FROM AUTHOR]

Background: Societies under duress may selectively increase the reporting of disordered persons from vulnerable communities to law enforcement. Mentally ill African American males reportedly are perceived as more threatening relative to females and other race/ethnicities. We examine whether law enforcement/court order-requested involuntary psychiatric hospitalizations increased among African American males shortly after ambient economic decline—a widely characterized population stressor.We identified psychiatric inpatient admissions requested by law enforcement/court orders from 2006 to 2011 across four US states (Arizona, California, New York, North Carolina). Our analytic sample comprises 13.1 million psychiatric inpatient admissions across 95 counties over 72 months. We operationalized exposure to economic downturns as percent change in monthly employment in a metropolitan statistical area (MSA). We used zero inflated negative binomial and linear fixed effects regression analyses to examine psychiatric inpatient admissions requested by law enforcement/court orders following regional employment decline over a time period that includes the Great Recession of 2008.Findings.Declines in monthly employment precede by one month a 6% increase in psychiatric hospitalizations requested by law enforcement/court order among African American males (p < 0.05), but not among other race/sex groups. Estimates amount to an excess of 2554 involuntary admissions among African American males statistically attributable to aggregate-level employment decline.Economic downturns may increase involuntary psychiatric commitments among African American males. Our findings underscore the unique vulnerability of racial/ethnic minorities during economic contractions.Methods: Societies under duress may selectively increase the reporting of disordered persons from vulnerable communities to law enforcement. Mentally ill African American males reportedly are perceived as more threatening relative to females and other race/ethnicities. We examine whether law enforcement/court order-requested involuntary psychiatric hospitalizations increased among African American males shortly after ambient economic decline—a widely characterized population stressor.We identified psychiatric inpatient admissions requested by law enforcement/court orders from 2006 to 2011 across four US states (Arizona, California, New York, North Carolina). Our analytic sample comprises 13.1 million psychiatric inpatient admissions across 95 counties over 72 months. We operationalized exposure to economic downturns as percent change in monthly employment in a metropolitan statistical area (MSA). We used zero inflated negative binomial and linear fixed effects regression analyses to examine psychiatric inpatient admissions requested by law enforcement/court orders following regional employment decline over a time period that includes the Great Recession of 2008.Findings.Declines in monthly employment precede by one month a 6% increase in psychiatric hospitalizations requested by law enforcement/court order among African American males (p < 0.05), but not among other race/sex groups. Estimates amount to an excess of 2554 involuntary admissions among African American males statistically attributable to aggregate-level employment decline.Economic downturns may increase involuntary psychiatric commitments among African American males. Our findings underscore the unique vulnerability of racial/ethnic minorities during economic contractions.Conclusions: Societies under duress may selectively increase the reporting of disordered persons from vulnerable communities to law enforcement. Mentally ill African American males reportedly are perceived as more threatening relative to females and other race/ethnicities. We examine whether law enforcement/court order-requested involuntary psychiatric hospitalizations increased among African American males shortly after ambient economic decline—a widely characterized population stressor.We identified psychiatric inpatient admissions requested by law enforcement/court orders from 2006 to 2011 across four US states (Arizona, California, New York, North Carolina). Our analytic sample comprises 13.1 million psychiatric inpatient admissions across 95 counties over 72 months. We operationalized exposure to economic downturns as percent change in monthly employment in a metropolitan statistical area (MSA). We used zero inflated negative binomial and linear fixed effects regression analyses to examine psychiatric inpatient admissions requested by law enforcement/court orders following regional employment decline over a time period that includes the Great Recession of 2008.Findings.Declines in monthly employment precede by one month a 6% increase in psychiatric hospitalizations requested by law enforcement/court order among African American males (p < 0.05), but not among other race/sex groups. Estimates amount to an excess of 2554 involuntary admissions among African American males statistically attributable to aggregate-level employment decline.Economic downturns may increase involuntary psychiatric commitments among African American males. Our findings underscore the unique vulnerability of racial/ethnic minorities during economic contractions. [ABSTRACT FROM AUTHOR]

Community Health Centers (CHCs) target medically underserved communities and expanded by 70% in the last decade. We know little, however, about mental health services at CHCs. We analyzed data from 2006 to 2015 and determined county-level drivers of these services. Mental health patients at CHCs fall from 2006 to 2007 but then rise consistently from 2007 to 2015. Counties with fewer physicians, greater percent insured and greater percent white population show faster growth in mental health services. Increases in mental health services at CHCs outpace general CHC growth and reflect federal efforts to integrate behavioral health care into primary care. [ABSTRACT FROM AUTHOR]