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This study aimed to evaluate associations of Medicaid expansion with health care access for adults with obesity and to explore racial/ethnic differences in these changes in health care access.Using 2011 to 2017 Behavioral Risk Factor Surveillance System data, the study compared health care access measures among adults who were aged ≥18 years and who had BMI ≥ 30 kg/mMedicaid expansion was associated with improvements in health care access, including lower proportions of those without a usual source of care (-3.6%, 95% confidence interval [CI]: -5.8% to -1.4%, p 0.01) and cost as a barrier to medical care (-4.5%, 95% CI: -7.0% to -1.9%, p 0.01). No significant changes were found in routine medical checkups in the last year (-1.8%, 95% CI: -4.4% to 0.8%, p = 0.12). However, across these measures, Medicaid expansion was consistently associated with better access among non-Hispanic White adults (-6.0% to -7.9%, p 0.01) and not at all among non-Hispanic Black and Hispanic adults (p 0.05).Medicaid expansion was associated with significant improvements in health care access among adults with obesity, but these improvements were variable across race and ethnicity.

The literature around co-payment shows evidence of increasing consumption following reduced co-payment. We apply difference-in-difference methods to assess the effect of abolishing the co-payment on psychologist treatment of anxiety and depression in 18 to 21-year olds. We apply nationwide individual level data with individuals close to this age interval as control group. The population amounts to approximately 1.2 million individuals and a total of 51 million patient months of observations. We show that after removing co-payment, the use of psychologist treatment almost doubles. We find that this increase involves moderately positive spill over effects on outpatient psychiatric care and on prescriptions of antidepressants. In the heterogeneity analysis we find evidence of higher effects on adolescents from families with lower income, indicating that reduced co-payments may increase equality in access. We also see that effects are higher for individuals listed with general practitioners (GPs) with a reluctant referral style; indicating that these GPs' behavior is affected by patient co-payment rates. Interestingly, we find evidence of significant reductions in suicide attempts - primarily among high-income women and low-income men. This indicates that better access to mental health care for adolescents may have a positive impact on their mental health and well-being.

To assess a new approach (weighting by "income probabilities [IP]") that uses US Census data from the patients' communities to approximate individual-level income, an important but often missing variable in health services research.Community (census tract level) income data came from the 2017 5-year American Community Survey (ACS). The patient data included those diagnosed with cancer in 2017 in Ohio (n = 65,759). The reference population was the 2017 5-year ACS Public Use Microdata Sample (n = 564,357 generalizing to 11,288,350 Ohioans).We applied the traditional approach of income approximation using median census tract income along with two IP based approaches to estimate the proportions in the patient data with incomes of 0%-149%, 150%-299%, 300%-499%, and 500%+ of the federal poverty level (FPL) ("class-relevant income grouping") or 0%-138%, 139%-249%, 250%-399%, and 400%+ FPL ("policy-relevant income grouping"). These estimated income distributions were then compared with the known income distributions of the reference population.The patient data came from Ohio's cancer registry. The other data were publicly available.Both IP based approaches consistently outperformed the traditional approach overall and in subgroup analyses, as measured by the weighted average absolute percentage point differences between the proportions of each of the income categories of the reference population and the estimated proportions generated by the income approximation approaches ("average percent difference," or APD). The smallest APD for an IP based method, 0.5%, was seen in non-Hispanic White females in the class-relevant income grouping (compared with 16.5% for the conventional method), while the largest APD, 7.1%, was seen in non-Hispanic Black females in the policy-relevant income grouping (compared with 18.0% for the conventional method).Weighting by IP substantially outperformed the conventional approach of estimating the distribution of incomes in patient data.

Urinary incontinence is a common condition in women, who often use incontinence containment products to self-manage. Few studies have sought to quantify use and costs of incontinence products associated with subtypes of incontinence and severity, therefore this study aimed to quantify incontinence product use and personal costs to women.This is a secondary analysis from a sample of adult women recruited electronically via ResearchMatch for a study on urinary symptoms and social determinants of health. Participants completed validated questionnaires on urinary symptoms, and were asked about daily numbers and types of incontinence products used and weekly costs, along with demographic and baseline clinical information, and information about unmet social needs. Descriptive statistics were performed, in addition to Wilcoxon rank sum and Kruskal-Wallis tests to compare incontinence product usage and cost based on type of incontinence, symptom severity, and other demographics, in addition to multivariable linear regression.A total of 702 women who reported using weekly incontinence products were included in the final analytic sample. Overall, women reported using a mean of 1.8 ± 2.1 incontinence products in 24 h (median: 1, interquartile range [IQR]: 1), with a maximum of 32. Mean weekly cost of was $5.42 ± $8.59 (median: $3, IQR: $4), with cost up to $100. Nonwhite women trended towards having higher product usage and cost, with significant cost increase seen among non-Hispanic Black women and Hispanic women. Usage and cost were higher in women who had less education, had household income below the poverty line, were on disability, were using Medicaid or were uninsured, had more unmet social needs, and in those with mixed incontinence. Additionally, daily product use and weekly costs increased with incontinence symptom severity, with the biggest increase between those with severe and very severe symptoms.In this study, we were able to quantify the number of incontinence products used daily and the weekly costs in incontinent women across types and severity of incontinence. Costs were even greater and may be prohibitive, in women with more unmet social needs, Medicaid or no insurance, less than a college education, lower income, or on disability.

Governments worldwide have issued massive amounts of debt to inject fiscal stimulus during the COVID-19 pandemic. This paper analyzes fiscal responses to an epidemic, in which interactions at work increase the risk of disease and mortality. Fiscal policies, which are designed to borrow against the future and provide transfers to individuals suffering economic hardship, can facilitate consumption smoothing while reduce hours worked and hence mitigate infections. We examine the optimal fiscal policy and characterize the condition under which fiscal policy improves social welfare. We then extend the model analyzing the static and dynamic pecuniary externalities under scale economies-the decrease in labor supply during the epidemic lowers the contemporaneous average wage rate while enhances the post-epidemic workforce health and productivity. We suggest that fiscal policy may not work effectively unless the government coordinates working time, and the optimal size of public debt is affected by production technology and disease severity and transmissibility.

Use of autism diagnosing standards in low-income countries (LICs) are restricted due to the high price and unavailability of trained health professionals. Furthermore, these standards are heavily skewed towards developed countries and LICs are underrepresented. Due to such constraints, many LICs use their own ways of assessing autism. This is the first retrospective study to analyze such local practices in Sri Lanka. The study was conducted at Ward 19B of Lady Ridgeway Hospital (LRH) using the clinical forms filled for diagnosing ASD. In this study, 356 records were analyzed, from which 79.5% were boys and the median age was 33 months. For each child, the clinical form together with the Childhood Autism Rating Scale (CARS) value were recorded. In this study, a Clinically Derived Autism Score (CDAS) is obtained from the clinical forms. Scatter plot and Pearson product moment correlation coefficient were used to benchmark CDAS with CARS, and it was found CDAS to be positively and moderately correlated with CARS. In identifying the significant variables, a logistic regression model was built based on clinically observed data and it evidenced that "Eye Contact," "Interaction with Others," "Pointing," "Flapping of Hands," "Request for Needs," "Rotate Wheels," and "Line up Things" variables as the most significant variables in diagnosing autism. Based on these significant predictors, the classification tree was built. The pruned tree depicts a set of rules, which could be used in similar clinical environments to screen for autism. LAY SUMMARY: Screening and diagnosing autism in low-income countries such as Sri Lanka has always been a challenge due to limited resources and not being able to afford global standards. Due to these challenges, locally developed clinical forms have been used. This study is the first to analyze a clinical record set for autism in Sri Lanka to benchmark the local clinic form with a global standard. Furthermore, this study identifies the most significant diagnostic symptoms for children and based on these significant features, a simple set of IF-THEN rules are derived which could be used for screening autism in a similar clinical environment by health officials in the absence of consultants.

ObjectiveTo describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease.Study settingNHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma.Study designThe initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies.Data collection/extraction methodsNot applicable.Principal findingsWe provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration.ConclusionsThe DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

The objective is to estimate the take-up of the Medicare Part D Low-Income Subsidy (LIS) among Medicare beneficiaries with diabetes and examine differences in out-of-pocket costs and prescription drug use between LIS enrollees and LIS-eligible non-enrollees. The LIS reduces out-of-pocket drug costs for low-income beneficiaries; however, not all LIS-eligible individuals are enrolled. Take-up of the LIS, and consequences of forgoing this benefit among beneficiaries with diabetes, remains unknown.Health and Retirement Study linked to Medicare administrative data from 2008 to 2016.We conducted two analyses among beneficiaries with diabetes. First, we estimated LIS take-up stratified by income (≤100% of the Federal Poverty Level [FPL] and100% to ≤150% of FPL). Second, to assess the consequences of forgoing the LIS among near-poor beneficiaries (incomes100% to ≤150% of FPL), we conducted propensity score-weighted regression analyses to compare out-of-pocket costs, the prescription drug use, and cost-related medication non-adherence among LIS enrollees and LIS-eligible non-enrollees.N/A.Among Medicare beneficiaries with diabetes, 68.1% of those with incomes100% to ≤150% of FPL received the LIS, while 90.3% with incomes ≤100% of FPL received the LIS. Among near-poor beneficiaries, LIS-eligible non-enrollees incurred higher annual out-of-pocket drug spending ($518; 95 [in USD]% CI: $370 [in USD], $667 [in USD]; p 0.001), filled 7.3 fewer prescriptions for diabetes, hypertension, and hyperlipidemia drugs (95% CI: -11.1, -3.5; p 0.001), and were 8.9 percentage points more likely to report skipping drugs due to cost (95% CI: 0.3, 18.0; p = 0.04), all compared to LIS enrollees.Despite providing substantial financial assistance with prescription drug costs, the LIS is under-utilized among beneficiaries with chronic conditions requiring routine medication use. As policy makers discuss Part D reforms to address rising out-of-pocket drug costs, they should consider strategies to increase participation in existing programs that alleviate cost burdens among low-income Medicare beneficiaries.

To determine whether preventive dental visits are associated with fewer subsequent nonpreventive dental visits and lower dental expenditures.Indiana Medicaid enrollment and claims data (2015-2018) and the Area Health Resource File.A repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and nonpreventive dental visits (NPVs) and dental expenditures.Not applicable.Of 28,152 adults (108,349 observation-years) meeting inclusion criteria, 36.0% had a dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = -0.13; 95% CI -0.12, -0.11), lower NPV expenditures (β = -$29.12.53; 95% CI -28.07, -21.05), and lower total dental expenditures (-$70.12; 95% -74.92, -65.31), as well as fewer PDVs (β = -0.24; 95% CI -0.26, -0.23).Our findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid-enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low-income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.

Resource constraints and widespread poverty among populations undermine disease prevention in low- and middle-income countries (LMICs) and ensure that these countries carry a disproportionate share of the global disease burden. Lack of access to efficacious medicines in LMICs further exacerbates this inequity. Addressing inequitable access to medicines and assuring their sustainable use is critical to the well-being of these populations. Whilst inadequate access to medicines in LMICs has drawn much attention, less is known about the sustainable use of available medicines, particularly to ensure their efficacy and mitigate harm to the population and the environment. Uganda has adopted various measures to ensure sustainable medicines use, including a national medicines policy, essential medicines list, medicines regulation framework and promotion of domestic medicines production. Despite progress, challenges remain to achieving sustainable medicines use in the country, including fragmented access, inappropriate use, poor quality and inappropriate disposal. There is a need to consolidate the globally embraced One Health approach (fostering collaboration between human, animal and environmental health sectors) to addressing these challenges as espoused in the country's One Health strategic plan. Medicines supply chain management in public sector health facilities needs to be strengthened to minimize inventory shortages (stock-outs). A strategy for universal health insurance can minimize economic barriers to medicines access. Enhanced professional and medicines regulation in the private health market needs to be implemented. There are opportunities to build further capacity in Uganda, particularly infrastructure for regulation of its healthcare systems, policy and governance, workforce capacity building, and population action and engagement.

I study the effect of rainfall shocks on child mortality at a sub-national level for a global set of developing countries. I establish that negative (positive) shocks to rainfall lead to an increase (drop) in child deaths overall. Low-income countries (LICs) and the group of countries reliant on agriculture are affected the most due to negative rainfall shocks. In LICs, the impact of negative rainfall shocks is mitigated by around 60% in districts located downstream to dams, an effect predominant among less affluent districts; in addition, the effect of rainfall fluctuations is persistent, lasting for up to three years following the shock. Results remain robust to the inclusion of relevant controls, to the consideration of relevant issues such as selective fertility and migration, and various other robustness tests.

The aim of this study was to explore experiences of homelessness in an affluent university town. Seven homeless men were recruited at a welfare program for homeless people to participate in in-depth, semistructured interviews that explored their experiences of homelessness in the town. The ages of the participants ranged from 36 to 52 years. There were three White participants, two of mixed race, and two Black participants. Thematic analysis was used to analyze the data, from a bottom-up systems perspective. The results revealed some of the participants' drug-related experiences, their structural experiences (e.g., shelter policy, low wages, and the poverty trap), their social experiences (e.g., the loss of their families and the lack of social standards in the homeless community), and their psychological experiences (i.e., fatalism, complacency, and responsibility). Subsidized housing and social grants are unlikely to effectively address the homelessness of men if other components of their experience, such as their drug-related experiences, their structural experiences, their social experiences, and their psychological experiences, are not attended to.

Several communities are implementing trauma-informed, community-level approaches focused on addressing/preventing adverse childhood experiences (ACEs), yet most community resilience definitions from published articles are based on acute traumas. This scoping review aims to determine how community resilience is defined and operationalized within the context of chronic/complex traumas.We performed a rigorous, comprehensive literature search using multiple databases.The 38 included articles addressed multiple types of chronic traumas, including historical trauma, poverty, minority stress, mass incarceration, and ACEs. A variety of definitions of community resilience were cited, several of which stressed the ability to thrive despite risk factors and the safety and wellbeing of residents. Few articles operationalized community resilience within the context of ACEs, suggesting significant gaps in the literature.This review can serve as an important building block to develop expanded definitions of community resilience for chronic traumas and assist communities in promoting community-wide responses to ACEs.

Policy Points Clarifications to Senate Bill (SB)1152 are necessary to address the differences between inpatient and emergency department (ED) discharge processes, determine how frequently an ED must deliver the SB1152 bundle of services to a single patient, and establish expectations for compliance during off-hours when social services are unavailable. Because homelessness cannot be resolved in a single ED visit, the state should provide funding to support housing-focused case workers that will follow patients experiencing homelessness (PEH) through the transition from temporary shelters to permanent supportive housing. Medi-Cal could fund the delivery of the SB1152 bundle of services to defray the costs to public hospitals that provide care for high numbers of PEH. California legislators should consider complementary legislation to increase funding for shelters so that sufficient capacity is available to accept PEH from EDs and hospitals, and to fund alternative strategies to prevent poverty and the upstream root causes of homelessness itself.ContextPrompted by stories of "patient dumping," California enacted Senate Bill (SB) 1152, which mandates that hospitals offer patients experiencing homelessness (PEH) a set of resources at discharge to ensure safety and prevent dumping.MethodsTo evaluate interventions to meet the requirements of SB1152 across three emergency departments (EDs) of a Los Angeles County public hospital system with a combined annual census of 260,000 visits, we used an explanatory sequential mixed methods approach, focusing first on quantitative evaluation and then using information from qualitative interviews to explain the quantitative findings.FindingsIn total, 2.9% (1,515/52,607) of encounters involved PEH. Documentation of compliance with the eight required components of SB1152 was low, ranging from 9.0% to 33.9%. Twenty-five provider interviews confirmed support for providing assistance to PEH in the ED, but the participants described barriers to compliance, including challenges in implementing universal screening for homelessness, incongruity of the requirements with the ED setting, the complexity of the patients, and the limitations of SB1152 as a health policy.ConclusionsDespite operationalizing universal screening for homelessness, we found poor compliance with SB1152 and identified multiple barriers to implementation.

This study aimed to understand the determinants of child marriages, becoming a child mother, their impacts and opinions about preventive strategies.The phenomenological research approach was adopted with one-to-one semi-structured interviews between December 2017 and May 2018.The population of the study consisted of 36 adolescent married mothers registered in the Family Health Centres. Interviews were recorded, transcribed and evaluated based on a thematic analysis was conducted.In the study, four main themes and 12 subthemes were determined. Adolescent marriages determinants occurred as patriarchal cultural norms, the perception that girls would be safe under the protection of another man, and poverty. Adolescent brides experienced partner violence and were subjected to physical, psychological and sexual violence in their marriage. Adolescent mothers had low maternal self-confidence, childcare challenges and were late to take on childcare responsibilities, and their children were neglected. As a result of early marriage, the participants experienced psychological problems and burnout later in their lives. Improving family-child communication, and eliminating financial inadequacies were among the opinions on prevention strategies of child marriages.The findings of this study identified the determinants and impact of adolescent marriages and revealed the problems experienced by adolescent brides and mothers.The most important contribution of this study is that it deals with the motherhood experiences. In addition, it is one of the important findings of this study that it draws attention to their neglected children's due to lack of knowledge and experience of their mothers about childcare.

Even when heavily subsidized, a substantial portion of people choose to forgo purchasing health insurance coverage. In this note, I introduce an explanation for this phenomenon which does not assume choice errors, incorrect beliefs, differently priced uncompensated care, or information asymmetries. When individuals are incapable of freely trading off health and wealth and the initial allocation of goods is suboptimal from their perspective, the standard result of demand for actuarially fair insurance in a single good world does not generalize to the health insurance context. Thus, people might not purchase full health insurance coverage even if it is priced at actuarially fair levels. I argue that this situation is particularly likely to occur in the low‐income population, and hence it is relevant for the achievement of universal health coverage.

To analyze the assessment of attitudes about poverty used in nursing education considering the first Sustainable Development Goal targets. Tools assessing attitudes about poverty have been used in nursing education studies to examine the beliefs of nursing students.An integrative literature review was carried out in five international databases in the areas of health and nursing and in four Latin American and Caribbean databases.Four tools were identified, with Attitude Toward Poverty Short Form and Attitudes about Poverty and Poor People being the most used in the studies. Items from tools measured attitudes negative, prejudiced, and stigmatizing about the population living in poverty. In addition, items from tools measured a range of concepts from poverty to social inequality and disenfranchisement.The identification of poverty is a critical strategy for tackling poverty. In this sense, poverty assessment tools have the potential to recognize poverty as a multidimensional phenomenon.

This study investigated the influence of childhood adversity, such as peer bullying and socioeconomic status, on the suicidal behaviour of left-behind Chinese adolescents to determine whether psychotic-like experiences (PLEs) mediated the associations between these childhood adversities and suicidality; suicidal ideation (serious thoughts about taking one's own life), suicide plans, and suicide attempts.A representative group of rural adolescents (n = 3346) was recruited from 16 rural high schools in China. Suicidality was assessed using the suicide module from the Mini International Neuropsychiatric Interview Kid. Participants also completed questionnaires on bullying, socioeconomic status, left-behind characteristics, and PLEs. Structural equation modelling was then employed to explore the relationships between these variables.Peer bullying, poverty, and left-behind status were all found to significantly increase adolescent suicide risk, the relationships between which were mediated by PLEs. Peer bullying was found to play the most significant role in the PLEs and suicidality, with the risk of suicide increasing with the length of time a child had been left behind.Adverse life events can lead to a high risk of PLEs, which in turn can increase the risk of suicide. These results could assist in identifying individuals at risk of suicidality and the design of appropriate interventions. The results also highlighted the role PLEs play in suicidality and highlighted the need for further research in this area.

Background: Mental illnesses are the leading causes of global disease burden. The impact is heightened in low- and middle-income countries (LMICs) due to embryonic care systems and extant barriers to healthcare access. Understanding children and adolescents' conceptualisations of mental health wellbeing in these settings is important to optimize health prevention and promotion initiatives. Objective: To systematically review and synthesize children and adolescents' conceptualisations and views of mental health and wellbeing in LMICs. Design: Ten databases were systematically searched from inception to July 2020 and findings from included studies were synthesized. Results: Twenty papers met eligibility criteria comprising qualitative, quantitative and mixed methods studies. Children and adolescents identified aspects of mental health and wellbeing, including positive affect and outlook and having sufficient personal resources to face daily challenges. Identified factors recognized the importance of activating both kin and lay networks in supporting and maintaining wellbeing. Conceptualisations of mental health and wellbeing were varied and influenced by culture, developmental stage and gender. Discussion and Conclusions: Irrespective of environmental and sociocultural influences on concepts of wellbeing and mental health, children and adolescents in LMICs can conceptualise these constructs and identify how they pursue positive mental health and wellbeing important for developing age and culture-appropriate community mental health strategies. Our review highlights the need to extend inquiry to wider developmental stages and both across and within specific populations in LMICs. Patient and Public Involvement: Initial results were presented at stakeholder workshops, which included children, adolescents, parents and health professionals held in Indonesia in January 2019 to allow the opportunity for feedback.

Subjective adulthood, or feeling like an adult, captures identity development relative to the local context that shapes life course processes. Most research on this topic is conducted in wealthy developed countries. Instead, we draw on household-based survey data from the Family Migration and Early Life Outcomes project (FAMELO) to estimate ordinal logistic regression models predicting how often adolescents ages 11 to 17 in Jalisco, Mexico (n = 1,567); Gaza Province, Mozambique (n = 1,368); and the Chitwan Valley, Nepal (n = 1,898) identify as adults. The relationships between adult roles, family capital, youth characteristics, and youths’ adult identities vary substantially across the sites. The findings highlight how the transition to adulthood reflects the cultural and structural conditions of adult identities.

Prior research underscores the importance of fathers' involvement in their children's lives. However, there is mixed evidence about the degree to which fatherhood programs improve economic stability and child support outcomes among noncustodial fathers. We attempted to address some of these gaps in the literature by evaluating the Fathers Advancing Community Together (FACT) program. FACT was implemented by Rubicon Programs, a community-based nonprofit organization in the Bay Area, California known for providing services to help move people out of poverty. The program provided parents economic stability, responsible parenting, and healthy relationship workshops, as well as support services and intensive case management. We relied on data from the Department of Child Support Services to assess whether FACT increased the likelihood of employment, child support modifications, and child support payments among noncustodial fathers during a 6-month post-enrollment period. Using 3:1 coarsened exact matching procedures, the total sample resulted in 744 fathers (186 in the intervention group and 558 in the comparison group). Results from logistic regression models indicate that FACT participants were more likely to be employed and more likely to receive a child support modification during the post-enrollment period than their comparison counterparts, though we found no significant relationship between FACT participation and whether fathers made a child support payment.Investigaciones previas subrayan la importancia de la participación de los padres en las vidas de sus hijos. Sin embargo, hay datos contradictorios acerca del grado en el cual los programas sobre la paternidad mejoran los resultados en la estabilidad económica y la manutención infantil entre los padres que no tienen la custodia de sus hijos. Intentamos abordar algunos de estos vacíos en las publicaciones evaluando el programa “Padres que fomentan la comunidad juntos” (Fathers Advancing Community Together, FACT). El programa FACT fue implementado por Rubicon Programs, una organización comunitaria sin fines de lucro en el Área de la Bahía de California, conocida por prestar servicios para ayudar a las personas a salir de la pobreza. El programa ofreció talleres de estabilidad económica para los padres, crianza responsable y relaciones sanas, así como servicios de apoyo y gestión intensiva de casos. Utilizamos datos del Departamento de Servicios de Manutención Infantil (Department of Child Support Services) para evaluar si el FACT aumentó la probabilidad de empleo, las modificaciones en la manutención infantil y los pagos de la manutención infantil entre padres sin la custodia de sus hijos durante un periodo de seis meses posterior a la inscripción. Utilizando métodos de emparejamiento exacto 3:1, la muestra total dio como resultado 744 padres (186 en el grupo de intervención y 558 en el grupo de comparación). Los resultados de los modelos de regresión logística indican que los participantes del FACT tuvieron más probabilidades de ser empleados y de recibir una modificación en la manutención infantil durante el periodo posterior a la inscripción que sus homólogos del grupo de de comparación, aunque no encontramos una relación significativa entre la participación en el FACT y si los padres hicieron un pago de manutención infantil.以往的研究强调父亲参与其子女生活的重要性。然而，关于父亲计划在多大程度上改善了那些非监护人父亲的经济稳定性和儿童抚养结果，其证据好坏参半。针对文献中的这些空白，本文通过试图评估 "父亲共同促进社区"（FACT）计划来充实此类研究。FACT由RUBICON PROGRAMS实施，这是加州湾区的一个社区非营利组织，以提供服务帮助人们摆脱贫困而闻名。该计划为父母提供经济稳定、负责任的养育方式，健康关系研讨会，以及支持性服务和高强度的个案管理。我们依靠儿童抚养服务部门的数据来评估FACT是否增加了非监护人父亲在参加后六个月内的就业可能性、儿童抚养费变化和儿童抚养费支付的可能性。总样本为744名父亲（干预组186人，对比组558人），使用了3:1的粗略精确匹配程序。逻辑回归模型的结果表明，与对比组相比，FACT参与者更有可能找到工作，也更有可能在参加后获得儿童抚养费的变化，尽管我们发现参与到FACT中与父亲是否支付儿童抚养费之间没有明显的关系。.

Background and aims Homelessness is one of the most significant harms associated with gambling and appears to affect older adults disproportionately, but the relationship has received little research attention. This exploratory study investigated how gambling and homelessness is linked in older adults. Methods Using qualitative research methods, we undertook in-depth semi structured face-to-face individual and group interviews to gather data from a purposive sample (n=48) of key informants working in service provision for older adults (aged 50+ years) experiencing gambling related harm and/or homelessness in Victoria, Australia. Thematic analysis of data focused on evaluating mechanisms and identifying contextual conditions that activate pathways between gambling and homelessness. Results The relationship between gambling and homelessness in older adults is often indirect and non-linear, and can represent a reflexive cycle. Experiencing periods of homelessness into older age can contribute to gambling, often because the adverse impacts of homelessness on older adult's mental and material wellbeing increase the appeal of gambling. Additionally, comorbidities (e.g. substance use, mental illness, past trauma) and structural conditions (e.g. gambling accessibility, poverty, housing insecurity) can activate gambling. Furthermore, because gambling in the older homeless adult population is frequently hidden, and regularly overlooked by service providers, it often continues unabated. Gambling in older adults can also contribute to the onset of first-time homelessness. Large and rapid losses from high-intensity gambling frequently characterise this route to homelessness. Such gambling is often triggered by major life events and changes (e.g. bereavement, job loss, relationship difficulties), and the outcomes are often worsened by the conduct of gambling operators and creditors. Conclusions The link between gambling and homelessness in older adults is complex, with connecting mechanisms often contingent on individual, interpersonal and structural conditions and contexts. There is potential for preventative and ameliorative action given many of the underlying conditions appear modifiable through policy intervention.

Very little is known about how Black Americans living in low-resourced communities define and maintain wellbeing. Utilizing a culturally tailored research design, we explored the phenomenon of wellbeing as it resonated with the lived experiences of our informants (N = 35). Using a thematic analysis, we found that existing conceptualizations and theorizing of wellbeing did not consistently emerge from our data. First, we noted paradoxical tensions between descriptions of wellbeing as indicated by the participants (e.g., being alive and having a pain-free life) and the Western, Eurocentric views evidenced in the wellbeing literature. Second, participants identified intergenerational family ties and community networks as ways that foster wellbeing. These findings suggest that we can no longer delimit and apply existing views in theorizing and measuring wellbeing. Our findings elucidated the mindsets, relationships, activities, and practices that define and foster wellbeing among Black Americans living in low-resourced communities.

OBJECTIVES To determine whether children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) had more caregiver-reported preventive dental care visits (PDCVs) and preventive dental services (PDS) than nonparticipating children. METHODS A secondary data analysis was performed utilizing the National Survey of Children's Health 2017 and 2018 combined datasets. The analytic sample included 10,356 children aged 1-4 years. It was further stratified into three groups by WIC eligibility and participation to include WIC participation, income-eligible nonparticipants, and higher-income nonparticipants. The independent variables included child-level characteristics (age, sex, race/ethnicity, and insurance) and caregiver-level characteristics (age of mother and the highest level of education in the household). The dependent variable was the report of PDCV and PDS (dental cleaning, toothbrushing instructions, and fluoride treatment) in the past 12 months. RESULTS Of the 10,356 children aged 1-4 years, 3025 were eligible for WIC and nearly half of those eligible (49.5%) reported participating in the WIC program. Caregivers of WIC-participating children had a higher reported prevalence of PDCV for their children than those of income-eligible nonparticipants (57.6% vs. 49.6%, respectively) (p

Background During a pandemic, the occurrence of infections and case fatality rates are expected to vary from one country to another due to several variables such as poverty, existing comorbidities, population density, access to health care, availability and quality of health system resources, and environmental factors. Objectives Our aim is to investigate the relationship between various demographic and socioeconomic factors and reported COVID‐19 morbidity and mortality indicators in different countries. Also, to determine the position of the countries relative to each other in terms of three indicators including COVID‐19 cases, deaths and tests. Methods Canonical correlation analysis is used to investigate the intercorrelations between independent variables and the COVID‐19 cases and deaths for 92 countries. Countries' performances are measured by MULTIMOORA. Results Human Development Index, smoking habits, percentage of elderly population and test frequency are the most significant variables associated with COVID‐19 morbidity and mortality according to our study findings. Singapore, New Zealand and Australia are the best performed countries. Conclusions Several significant and unexpected associations exist between socioeconomic factors and the COVID‐19 cases and deaths. Singapore, New Zealand and Australia are surrounded by water, have been more successful in the pandemic process compared to other countries., Key points HDI, smoking habits, elderly population, and test frequency, were the most significant factors associated with COVID‐19 mortality and morbiditySingapore, New Zealand, and Australia, that are surrounded by water, have better performance in the pandemic process than other countriesSlovenia, Czech Republic, and Croatia have less favourable performance in the pandemic process compared to other countries

Humans in their increasing numbers and wealth are changing ecosystems through accelerated consumption of food, natural resources and energy which continue to cause significant damage to the planet. Using 'stunting in children' as a case study, we show how the traditional siloed (specialist) approaches have failed to reduce stunting world-wide. Despite significant effort, traditional approaches fail to appreciate the interconnectedness of the multiple factors that underpin stunting. We will not improve the lives of the millions of children living in poverty by doing the same things we have always done, rather we need to adopt approaches that recognise the interconnectedness of all the component parts and apply One Health methods designed to solve these intractable problems.

This paper analyses method skew in India over more than two decades using a new method skew index. The analysis reveals clear regional pattern in method skew in the country. In north and east regions of the country, method skew is average and below average, but it is high or very high in the south region. We investigate roles of such factors as poverty, education, social class, and religion in deciding the method skew at the district level using the classification modeling approach and find that the roles of these factors are different in different regions of the country. An important finding of the analysis is that there is a positive correlation between the degree of the method skew and contraceptive prevalence at the district level.

Experimental research demonstrates sustained high-quality early care and education (ECE) can mitigate the consequences of poverty into adulthood. However, the long-term effects of community-based ECE are less known. Using the 1991 NICHD Study of Early Child Care and Youth Development (n = 994; 49.7% female; 73.6% White, 10.6% African American, 5.6% Latino, 10.2% Other), results show that ECE was associated with reduced disparities between low- and higher-income children's educational attainment and wages at age 26. Disparities in college graduation were reduced the more months that low-income children spent in ECE (d = .19). For wages, disparities were reduced when children from low-income families attended sustained high-quality ECE (d = .19). Findings suggest that community-based ECE is linked to meaningful educational and life outcomes, and sustained high-quality ECE is particularly important for children from lower-income backgrounds.

Global child mortality has more than halved for the last three decades. Without a decrease in morbidity corresponding to that in mortality, this increased survival is likely to increase the number of children with disabilities, especially in low- and middle-income countries (LMICs). While population-based data on children with disabilities have been scarce in LMICs, it is estimated that among 52.9 million children with disabilities under 5 years worldwide, 95% live in LMICs. Sequelae of postnatal disease continue to be the major cause of child disability in LMICs; however, disability is increasingly the result of perinatal conditions. The Convention on the Rights of the Child and the Convention on the Rights of Persons with Disabilities promote the rights of children with disabilities, but limited resources in LMICs have prevented the translation of policies reflecting these Conventions into practice. Because health care for children with disabilities is limited in LMICs, most of them are cared for at home. This places heavy physical and mental burden on family caregivers and affects the allocation of time and financial resources in the family. Simple interventions can dramatically improve the clinical condition of disabled children and should be applied in care at home. Legally recognized members of society, children with disabilities remain excluded from public support. Disabled children must be empowered to overcome this inequity. This is the focus of the "Nothing About Us Without Us" campaign. Society, including professionals, can further redistribute power by "putting the first last" to empower individuals with disability.

Background The COVID‐19 pandemic has overrun hospital systems while exacerbating economic hardship and food insecurity on a global scale. In an effort to understand how early action to find and control the virus is associated with cumulative outcomes, we explored how country‐level testing capacity affects later COVID‐19 mortality. Methods We used the Our World in Data database to explore testing and mortality records in 27 countries from December 31, 2019, to September 30, 2020; we applied Cox proportional hazards regression to determine the relationship between early COVID‐19 testing capacity (cumulative tests per case) and later COVID‐19 mortality (time to specified mortality thresholds), adjusting for country‐level confounders, including median age, GDP, hospital bed capacity, population density, and nonpharmaceutical interventions. Results Higher early testing implementation, as indicated by more cumulative tests per case when mortality was still low, was associated with a lower risk for higher per capita deaths. A sample finding indicated that a higher cumulative number of tests administered per case at the time of six deaths per million persons was associated with a lower risk of reaching 15 deaths per million persons, after adjustment for all confounders (HR = 0.909; P = 0.0001). Conclusions Countries that developed stronger COVID‐19 testing capacity at early timepoints, as measured by tests administered per case identified, experienced a slower increase of deaths per capita. Thus, this study operationalizes the value of testing and provides empirical evidence that stronger testing capacity at early timepoints is associated with reduced mortality and improved pandemic control.

The link between socioeconomic status and posttraumatic stress disorder (PTSD) symptoms is well established. Given that Black women are disproportionately burdened by both poverty and PTSD symptoms, research focusing on these constructs among this population is needed. The current study assessed the association between material hardship (i.e., difficulty meeting basic needs) and PTSD symptoms among 227 low-income Black women in the United States. We explored several potential explanations for the association between poverty and PTSD symptoms (e.g., individuals living in poverty may experience higher levels of trauma exposure; individuals living in poverty may have less access to relevant protective resources, like social support; poverty itself may represent a traumatic stressor). Using robust negative binomial regression, a positive association between material hardship and PTSD symptoms emerged, B = 0.10, p = .009, SMD = 0.08. When trauma exposure was added to the model, it was positively associated with PTSD symptoms, B = 0.18, p < .001, SMD = 0.16, and material hardship remained positively associated with PTSD symptoms, B = 0.10, p = .019, SMD = 0.08. When social support indicators were added to the model, they were not associated with PTSD symptoms; however, material hardship remained significantly associated, B = 0.10, p = .021, SMD = 0.08. In the model with material hardship and trauma exposure, a significant interaction between material hardship and trauma exposure on PTSD symptoms emerged, B = −0.04, p = .027. These results demonstrate the importance of including material hardship in trauma research, assessment, and treatment.

While extensive research has supported the developmental programming hypothesis regarding contributions of prenatal psychosocial or nutritional adversity to offspring stress physiology, fewer studies consider both exposures together with maternal stress physiology. This study examined newborn cortisol output during a stressor as a function of maternal pre-pregnancy health status and nutritional history (pre-pregnancy body mass index [PPBMI]), economic resources (household income), and maternal cortisol awakening response (mCAR) in late pregnancy. Participants were 102 mother-infant pairs from an economically and racial/ethnically diverse sample. Offspring salivary cortisol response to a neurobehavioral exam was assessed at 1 month. Income and maternal PPBMI were positively associated with mCAR in late pregnancy. mCAR was positively related to 1-month newborn cortisol response. The interaction of income and PPBMI was positively associated with newborn cortisol output during an exam at 1-month. Mothers with the highest PPBMI and lowest income had offspring with higher cortisol responses than offspring of mothers with higher income and lower PPBMI. There was no evidence of indirect mediation effects of predictors (PPBMI, income, and interaction) on infant cortisol via mCAR. The differential effects of the interaction of PPBMI and income suggest that these exposures influence infant cortisol output in the context of one another, independent of maternal pregnancy cortisol.

Funder: Emmanuel College, University of Cambridge; Id: http://dx.doi.org/10.13039/501100000609, Funder: Gates Cambridge Trust; Id: http://dx.doi.org/10.13039/501100005370, Funder: Jacobs Foundation; Id: http://dx.doi.org/10.13039/501100003986, Funder: University of Cambridge; Id: http://dx.doi.org/10.13039/501100000735, Funder: Wellspring Foundation, BACKGROUND: Adolescence is a period of life when young people increasingly define themselves through peer comparison and are vulnerable to developing mental health problems. In the current study, we investigated whether the subjective experience of economic disadvantage among friends is associated with social difficulties and poorer mental health in early adolescence. METHODS: We used latent change score modelling (LCSM) on data from the UK Millennium Cohort Study, collected at ages 11 and 14 (N = 12,995). Each LCSM modelled the mean of an outcome related to mental health and interpersonal difficulties at age 11 (including self-esteem, well-being, emotional difficulties, peer problems, bullying, victimisation and externalising difficulties), the change of the outcome from ages 11 to 14 and its predictors, including perceived income inequality among friends (i.e. perceiving oneself as belonging to a poorer family than the families of one's friends). RESULTS: Perceived income inequality predicted adverse mental health and a range of interpersonal difficulties during adolescence, even when controlling for objective family income. Follow-up analyses highlighted that, at 11 years, young people who perceived themselves as belonging to poorer families than their friends reported worse well-being, self-esteem, internalising problems, externalising problems and victimisation at the same age (relative to those who perceived themselves as richer than or equal to their friends, or who did not know). Longitudinal analyses suggested that victimisation decreased from ages 11 to 14 to a greater extent for adolescents who perceived themselves as poorer than other adolescents. CONCLUSIONS: The salience of economic inequalities in proximal social environments (e.g. among friends) in early adolescence could further amplify the negative effects of economic disadvantage on mental health and behavioural difficulties during this period.

Aim To determine prevalence and predictors of perceived stress in women with threatened preterm labour. Design Cross‐sectional. Methods We recruited 409 women with threatened preterm labour, hospitalized at two tertiary hospitals. We assessed their socio‐demographic and obstetrics characteristics, and their perceived stress, perceived social support, experience of violence using validated scales. Multiple linear regression was used to determine the predictors. Results Data from all recruited women were analysed. Most of them had borderline (36%) or high (42%) level stress. Overall, 17 predictors were identified explaining 89.5% of variation in the stress score. Predictors of the higher stress score included: urban living, experience of sexual and psychological violence, perceived insufficient social support, experience of vaginal bleeding during current pregnancy, abnormal results in initial pregnancy tests, having multiple roles at home, being less than 28 weeks pregnant, being parous, sleep disorders, history of health problems, insufficient income and unwanted pregnancy.

This paper investigates the mutual relationship between gender-based violence (GBV) and cyclone-related disasters. Evidence is sparse on this topic, especially in-depth research attending to the cultural and socioeconomic aspects of locality. The work reported here is based on a case study of a coastal district of Bangladesh (Barguna)-conducted shortly after Cyclone Roanu struck the country in May 2016-that aimed to shed light on the mechanisms linking GBV to cyclones through the eyes of survivors. The paper maps out the different forms, experiences, and impacts of GBV before, during, and after cyclones, and argues that such events lead directly and indirectly to GBV, and that GBV makes women and children more vulnerable to the effects of disasters. Climate change, economic losses, and poverty compound this cyclical relationship. A conceptual framing, drawing on the notion of 'slow violence', is developed to understand the layering of diverse types of violence that operate on seemingly different temporal and spatial scales.

Background Racial and ethnic minority status, structural racism, low educational attainment, and poverty are consistently associated with cancer disparities and with higher rates of incarceration. The objective of this scoping review is to conduct a qualitative synthesis of the literature on cancer prevalence, incidence, mortality, and disparities in these outcomes for incarcerated and formerly incarcerated patients, as this literature is fragmented and heterogenous. Methods This scoping review included Bureau of Justice Statistics reports and searched PubMed in May 2021 for all English language studies published between 1990 and 30 April 2021, that reported on cancer prevalence, incidence, or mortality for incarcerated or formerly incarcerated individuals in the United States. Results Twenty studies were selected. Data on cancer prevalence and incidence were scarce but suggested that incarcerated and formerly incarcerated patients have a similar overall risk of cancer diagnosis as the general population, but elevated risk of certain cancers such as cervical, lung, colorectal, and hepatocellular carcinoma for which effective prevention and screening interventions exist. Cancer mortality data in state and local jails as well as prisons were robust and suggests that both incarcerated and formerly incarcerated patients have higher cancer mortality than the general population. Conclusions Incarcerated and formerly incarcerated patients likely have a higher risk of dying from cancer than the general population, but important gaps in our knowledge about the extent and drivers of disparities for this population remain. Additional research is needed to guide interventions to reduce cancer disparities for patients experiencing incarceration., This scoping review finds that individuals who are currently or formerly incarcerated in prison have higher cancer mortality than the general population. However, important knowledge gaps remain that must be addressed to inform targeted interventions to reduce cancer disparities in prisons and in the community.

Aim This review aimed to determine the social determinants of healthy lifestyle among Iranian women. Design A systematic review and meta‐analysis. Method A comprehensive electronic search was carried out with no time limit until 6 September 2019. Newcastle–Ottawa Quality Assessment Scale (adapted for evaluating cross‐sectional survey/studies) was used to evaluate the quality of the articles. The metap code was used in SATATA16 to combine the p‐values using Edgington's additive method. Results Twelve studies entered the systematic review. The meta‐analysis results showed that social determinants of healthy lifestyle among Iranian women included income, job, education, spouse's education and occupation, housing and social support. Conclusions Given the relationship between modifiable factors and women's lifestyles, it seems that it is necessary to set policies to improve the status of factors related to women's lifestyle including reducing poverty, promoting education and providing social support to eliminate.

Obstetric violence is a pervasive phenomenon in reproductive health across the world. Denial of the choice in birth position is a common form of obstetric violence as horizontal positions are non-evidence based, yet routinely imposed. This contributes to the cultural barriers to access reproductive health care. The present study compares women's experiences in childbirth from the Quichua and Egyptian communities, exploring the intersectional factors that contribute to obstetric violence and the adoption of preferred birth positions to offer recommendations on implementing respectful and rights-based reproductive care. Two independent scoping reviews have been carried out and subsequently compared. The intersectional approach revealed how gender, race, and class have a multiplicative effect on the denial of choice in birth position as a form of obstetric violence. This phenomenon exacerbates the pre-existing health disparities that disproportionately affect women, indigenous and racialized groups, and people living in poverty. Culturally competent, multilevel, and multidisciplinary interventions, strengthening of health systems, and community participation are essential to combat discrimination and guarantee birth rights. Allowing women to choose their birth position is a low-hanging fruit to challenge the complex issue of obstetric violence and ensure a rights-based approach to reproductive health.

OBJECTIVE Ethnicity, neighbourhood ethnic density, and four additional neighbourhood factors (urbanicity, crime, voting, and poverty) were examined in relation to the incidence of first episode of psychosis (FEP) in the Pacific Island of Guam. METHODS All first contact patients seen at the Guam Department of Mental Health and Substance Abuse (DMHSA) between January 2005 and December 2007 that met DSM-IV criteria for the diagnosis of a psychotic disorder were included. At the time of the study, DMHSA was the only psychiatric facility in Guam. RESULTS After controlling for age and gender, Chamorros, the indigenous people of Guam, had a standardized incidence rate (IR = 151/100 000 person-years, 95%CI = 129-173) of FEP over twice that of Whites (IR = 66/100 000 person-years, 95%CI = 34-99). Individuals from Palau had the highest standardized incidence rate (IR = 832/100 000 person-years, 95%CI = 581-1083). Increased neighbourhood Chamorro density was associated with decreased incidence of FEP among Chamorro individuals (IRR = 0.11, 95%CI = 0.03-0.43). After controlling for age, gender, ethnicity, and other neighbourhood factors, urbanicity (IRR = 3.82, 95%CI = 1.86-7.81), voting (IRR = 2.06, 95%CI = 1.32-3.20), poverty (IRR = 1.94, 95%CI = 1.40-2.67), and crime (IRR = 1.18, 95%CI = 1.00-1.40) remained statistically associated with FEP incidence. CONCLUSIONS The findings add to prior research that suggests that rates of mental health problems are higher in indigenous than in settler communities and are highest for indigenous people who live in neighbourhoods with few other indigenous individuals. Findings also suggest that even on a small island, with only ~150 000 people, urbanicity is associated with FEP. Finally, results are consistent with other research suggesting that the reduction of crime and social adversity can play a positive role in reducing the incidence of first episode psychosis.

Background/objectives Health disparities encompass a wide range of personal, societal, environmental, and system-based factors that contribute to inequitable health and health outcomes in vulnerable patient populations. The goal of this work was to scientifically summarize the existing published North American research on disparity as it pertains to pediatric dermatology. Methods A systematic review was performed according to PRISMA guidelines. A medical librarian performed electronic searches from multiple electronic databases from their dates of inception to March 2021. Title and abstracts were reviewed by authors, identifying articles for full review. Data on article characteristics and identified disparities were then extracted and collected in a spreadsheet. Results Fifty-one articles met final inclusion criteria, of which 25 highlighted disparities due to race/ethnicity, 13 highlighted disparities due to socioeconomic (SES), and 13 highlighted disparities due to both race/ethnicity and SES. The most frequent study designs were cross-sectional or survey, followed by retrospective cohort. Only two were prospective cohort studies. Disparities reported included reduced access to care and medications, increased school absenteeism, reduced knowledge about skin care including sun protection, increased hospitalizations and emergency department visits, and severe and persistent disease in the setting of minority race and poverty, among other indicators. Conclusions There are few, scattered research studies addressing disparity in pediatric dermatology. Greater focus will be needed in the future to improve knowledge of sources of disparity and its detrimental effects on the health of children, to rectify the notable disparity under-reporting of disparity research.

Barriers facing effective science-to-practice translation have led scholars to conduct early-stage intervention research within community organizations. We describe our experiences developing a manualized parent-youth attachment-based group therapy intervention within a community health organization dedicated to serving low-income Latinx immigrant families, Latino Health Access (LHA), in which services are rendered by trained community workers (promotores). By conducting a qualitative analysis of interviews with all members of this academic-community partnership (research [Principal Investigator, student researchers] and community agency team members [Administrators, promotores]), we discuss the challenges and opportunities that this collaboration has generated. The results led both the research and community teams to question assumptions about the basic skills, values, and attitudes that underlie the integration of science and practice. We will share the insights that have helped to promote connection and understanding among the stakeholders and the efforts made to support the progress and successes of developing community interventions.Los obstáculos que enfrenta el traslado eficaz de la ciencia a la práctica han conducido a los investigadores a realizar investigaciones en etapas iniciales de las intervenciones dentro de las organizaciones comunitarias. Describimos nuestras experiencias con el desarrollo de una intervención estandarizada de terapia grupal basada en el apego entre padres y jóvenes dentro de una organización de salud comunitaria dedicada a asistir a familias inmigrantes latinas de bajos recursos, Latino Health Access (LHA), en la cual prestan servicios trabajadores comunitarios capacitados (promotores). Al realizar un análisis cualitativo de las entrevistas con todos los miembros de esta asociación académico-comunitaria (investigación [investigador principal, investigadores estudiantes] y los miembros del equipo de la organización comunitaria [administradores, promotores], comentamos las dificultades y las oportunidades que ha generado esta colaboración. Los resultados llevaron a los equipos comunitarios y de investigación a cuestionar las suposiciones acerca de las habilidades básicas, los valores y las actitudes que forman la base de la integración de la ciencia y la práctica. Compartiremos los conocimientos que han contribuido a promover la conexión y la comprensión entre las partes interesadas y los esfuerzos realizados para fomentar el avance y los logros de desarrollar intervenciones comunitarias.科学到实践的有效转化所面临的障碍牵引着学者们在社区组织内进行早期干预研究。本研究描述了我们在一个致力于为低收入拉美移民家庭服务的社区健康组织--拉丁裔健康通道（LHA）内开发基于父母-青年依恋的团体治疗手册式的干预措施的经验。在这个组织中，服务由训练有素的社区工作人员(推广人员)提供。通过对这一学术-社区合作伙伴关系的所有成员(研究[首席研究员，学生研究人员]和社区机构团队成员[行政人员，推广人员])的访谈进行定性分析，我们讨论了这一合作带来的挑战和机遇。研究结果促使研究团队和社区团队对支撑科学与实践结合的基本技能、价值观和态度的假设提出质疑。文中将分享有助于促进利益相关者之间的联系和理解的见解，以及为支持发展社区干预措施的进展和成功所作的努力。.

Objective To estimate and compare unmet health care needs of persons with spinal cord injury (SCI) across countries, the causes of these shortfalls, and the role of income. Data sources We analyzed cross-sectional data of 20 countries from the International Spinal Cord Injury (InSCI) survey, a compendium of comparable data on the living situation of persons with SCI. Data included information on high-, middle-, and low-income countries. The survey comprises information on 12,095 participants. Study design We used logit regressions to estimate the probability of unmet health care needs of persons with SCI and its causes. We adjusted the results by the individuals' characteristics and countries' fixed effects. We disaggregated the results by income decile of individuals in each country. Data collection/extraction methods The inclusion criteria for the InSCI survey were adults aged 18 years and older with SCI living in the community, who were able to respond to the survey and who provided informed consent. Principal findings Unmet health care needs are significant for people with long-term conditions like SCI, where people in low-income groups tend to be more affected. Among the barriers to meeting health care needs, the foremost is health care cost (in 11 of the 20 countries), followed by transportation and service availability. Persons with SCI in Morocco reported the highest probability of unmet health care needs in the sample, 0.54 (CI: 047-0.59), followed well behind by South Africa, 0.27 (CI: 0.20-0.33), and Brazil, 0.26 (CI: 0.20-0.33). In contrast, persons with SCI in Spain, 0.06 (CI: 0.04-0.08), reported the lowest probability of unmet health care needs, closely followed by Norway, 0.07 (CI: 0.05-0.09), Thailand, 0.08 (CI: 0.05-0.11), France, 0.08 (CI: 0.06-0.11), and Switzerland, 0.09 (CI: 0.07-0.10). Conclusions SCI is a long-term, irreversible health condition characterized by physical impairment and a series of chronic illness. This makes SCI a high-need, high-cost group that faces significant unmet health care needs, which are mainly explained by the costs of health services, transportation, and services availability. This situation is prevalent in low-, middle-, and high-income countries, where persons in lower income groups are disproportionately affected. To improve the situation, a combination of measures from the health and social systems are required.

OBJECTIVE To examine the out-of-pocket expenditure (OOPE), healthcare burden, catastrophic health expenditure, hardship financing and impoverishment effects of TB treatment in India. METHODS Data of three rounds of National Statistic Surveys 60th 2004-05, 71st 2013-14 and 75th 2017-18. Descriptive statistics, bivariate estimates and multivariate models were performed to calculate the OOPE, healthcare burden, catastrophic health expenditure, hardship financing and impoverishment using standard definitions at December 2019 price values. RESULTS More than two-thirds of the TB cases are seen in the economically productive age group (14-59 years). Illiterate patients had a higher healthcare burden and OOPE. The healthcare burden, hardship financing and catastrophic health expenditure are considerably higher for those utilising private hospitals. Male patients have a higher exposure to hardship financing than female patients. Impoverishment effects are higher among Hindus and illiterate populations due to utilisation of hospitalisation services. CONCLUSION The present analysis helps to understand the trends in the financial burden of TB on households over last 15 years, thus providing evidence to policymakers for more effective channelling of resources in order to achieve a TB-free India by 2025.

OBJECTIVE: To re‐evaluate the effect of Medicaid on poverty using a poverty measure that accounts for health insurance needs and benefits and an evaluation approach that reflects disparities in access to alternative coverage. DATA SOURCES: The Current Population Survey (CPS) for calendar year 2015. STUDY DESIGN: We estimate the effect of losing Medicaid on poverty, combining two previous approaches: (1) A propensity impact, which simulates a no‐Medicaid counterfactual incorporating changes to health insurance and medical out‐of‐pocket spending, using the Supplemental Poverty Measure (SPM). This measure does not reflect a need for health care access nor how health benefits meet that need. (2) An accounting impact, which assumes that those losing Medicaid remain uninsured and does not incorporate any behavioral changes, using the health‐inclusive poverty measure (HIPM). This measure includes a need for health insurance in the threshold and health insurance benefits in resources. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Using the propensity‐matched approach, we attributed a 2.5 percentage point reduction in health‐inclusive poverty among those younger than age 65 to the Medicaid program, between the 1.0‐point SPM propensity‐match impact and the 3.9‐point HIPM accounting impact. Medicaid's antipoverty impact and HIPM‐SPM differences are greater among those who would become uninsured. HIPM propensity‐matched estimates reveal much larger impacts of Medicaid on poverty disparities linked to race/ethnicity and single parenthood than SPM‐based propensity estimates. CONCLUSIONS: Both the poverty measure and the method used to estimate the counterfactual make substantial, policy‐relevant differences to estimates of Medicaid's impact on poverty. A poverty measure that fails to incorporate health insurance needs and benefits substantially underestimates Medicaid's effect. Failing to consider adjustments in insurance coverage and out‐of‐pocket spending substantially overestimates Medicaid's effect and underestimates its reduction of disparities.

Objectives Allostatic load (AL), defined as the overtime "wear and tear" on biological systems due to stress, disproportionately affects racial/ethnic minorities and has been shown to associate with racial inequality in oral health in the adult population. This study aims to assess racial/ethnic inequality in AL and untreated dental caries (UD) in children, and to assess the association between allostatic load and UD, and whether it varies by race/ethnicity. Methods Data from the National Health and Nutrition Examination Survey (NHANES) (2001-2010) for 8-17-year-old children (n = 11,378) was used. AL scores were generated using cardiovascular, metabolic and immune biomarkers. Multivariable log binomial regression models adjusted for age, sex, poverty: income ratio (PIR), health insurance status and the frequency of healthcare visits, were used to assess the relationships of interest. Results Racial/ethnic inequality was evident in UD and AL, where Mexican American and black children exhibited more UD and a higher AL score than white. AL was associated with UD in fully adjusted models. This association was significant across all racial/ethnic groups, but was stronger in Mexican American and black children, compared to their white counterparts. Conclusions Similar racial inequality is evident in AL and UD that is not explained by poverty and/or behavioral factors. Racial/ethnic inequality is also evident in the association between AL and UD.

POLICY POINTS: Purchasing health insurance is a complex task with multiple potential points of failure. In 2018, following the silver‐loading price shock, 20.2% of households earning above 200% of the federal poverty level with coverage through the two Covered California insurers who sold dominated silver plans purchased the inferior, dominated silver plan. Individuals who were automatically reenrolled were more likely to purchase an inferior, dominated plan. Automatic reenrollment rules and marketplace choice architecture should be modified to avoid placing people into dominated health insurance policies and help consumers more easily select superior coverage for themselves. CONTEXT: The Affordable Care Act (ACA) individual health insurance marketplaces rely on purchasers to make informed choices to impose price and quality discipline on a complex array of insurance products. A sudden and minimally expected policy shock in the fall of 2017—the termination of direct federal payment for cost‐sharing reduction (CSR) subsidies—led to a substantial change in the relative prices of silver and gold plans on the Covered California insurance marketplace. From 2014 to 2017, all gold plans in California were more expensive than comparable silver plans that were offered by the same insurer using the same network in the same county. For the 2018 plan year, however, some gold plans that had lower cost sharing also had lower premiums than did comparable silver plans, resulting in silver “dominated” plans being sold through Covered California. METHODS: We used the Covered California enrollment and product files from 2014 to 2018 in a retrospective data analysis of plan choice. We examined individuals earning above 200% of the federal poverty level who purchased plans from insurers who sold dominated silver plans in 2018. FINDINGS: We found that 3.9% of all Covered California enrollees in 2018 chose a strictly and transparently dominated plan. Among households with incomes above 200% of the federal poverty level that were enrolled in plans from the two insurers that offered dominated plans, 20.2% chose a dominated plan. Households that actively enrolled in 2018 and were enrolled in a silver plan in the previous year enrolled in a dominated plan at higher rates than did new enrollees and those who were enrolled in nonsilver plans in the previous year. More than 30% of households that had their coverage automatically renewed in 2018 enrolled in a dominated plan. On average, households enrolled in dominated plans in 2018 spent an additional $38.87 per month in premiums. CONCLUSIONS: Households routinely chose dominated plans and were exposed to both higher monthly premiums and higher potential cost sharing. Health insurance marketplaces should improve decision supports and choice curation to eliminate the possibility of individuals choosing dominated plans.

Introduction Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States. Methods Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach. Results Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking. Discussion This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

BACKGROUND Good quality parenting in early childhood is reliably associated with positive mental and physical health over the lifespan. The hypothesis that early parenting quality has significant long-term financial benefits has not been previously tested. METHODS Design: Longitudinal study with follow-up from 2012 to 2016. SETTING UK multicentre study cohort (London, South-East England). PARTICIPANTS 174 young people drawn from 2 samples, one at moderate risk of poor outcomes and one at high risk, assessed aged 4-6 years then followed up in early adolescence (mean age 12.1 years). MEASURES The primary outcome was total costs: health, social care, extra school support, out-of-home placements and family-born expenditure, determined through semistructured economic interviews. Early parenting quality was independently assessed through direct observation of parent-child interaction. RESULTS Costs were lower for youths exposed to more sensitive parenting (most sensitive quartile mean £1,619, least sensitive quartile mean £21,763; p

OBJECTIVE: Between January 2005 and July 2020, 171 rural hospitals closed across the United States. Little is known about the extent that other providers step in to fill the potential reduction in access from a rural hospital closure. The objective of this analysis is to evaluate the trends of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in rural areas prior to and following hospital closure. DATA SOURCES/STUDY SETTING: We used publicly available data from Centers for Medicare and Medicaid Provider of Services files, Cecil G. Sheps Center rural hospital closures list, and Small Area Income and Poverty Estimates. STUDY DESIGN: We described the trends over time in the number of hospitals, hospital closures, FQHC sites, and RHCs in rural and urban ZIP codes, 2006–2018. We used two‐way fixed effects and pooled generalized linear models with a logit link to estimate the probabilities of having any RHC and any FQHC within 10 straight‐line miles. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: Compared to hospitals that never closed, the predicted probability of having any FQHC within 10 miles increased post closure by 5.95 and 11.57 percentage points at 1 year and 5 years, respectively (p

Integrated conservation approaches (ICAs) are employed by governments, communities, and nongovernmental organizations worldwide seeking to achieve outcomes with dual benefits for biodiversity conservation and poverty alleviation. Although ICAs are frequently implemented concurrently, interactions among ICAs and the synergies or trade-offs that result are rarely considered during program design, implementation, and evaluation. In support of more deliberate and effective use of ICAs, we examined interactions among four well-known strategies: biosphere reserves (BRs), voluntary protected areas (VPAs), payments for ecosystem services (PES), and community forest management (CFM). Through a comparative case study, we analyzed interactions among spatially or temporally clustered ICAs implemented on communally held and managed lands in three ecologically and socioeconomically distinct regions of Mexico. Our research methods combined policy analysis with data gathered through participant observation and semistructured interviews (n = 78) and focus groups (n = 5) with government officials, implementers, and participants involved in ICAs in 28 communities. Despite the significant differences among the regions in which they were implemented, we found that key actors at each level of involvement generally perceived interactions among ICAs as synergistic. The PES programs were perceived to strengthen protected areas by reducing forest cover loss in and around BRs, fostering proconservation attitudes, and incentivizing the establishment of VPAs. Communities that invested PES income in CFM were motivated to conserve forests beyond the duration of PES programs, and CFM in buffer zones was perceived to strengthen BRs by maintaining forest cover and generating income for communities. We also identified key social and environmental factors that can influence these interaction effects among ICAs. Based on these findings, we recommend further study of ICA interactions and intentionally complementary policy design to maximize positive environmental and social outcomes.Las estrategias de conservación integrada (ECI) son empleadas en todo el mundo por los gobiernos, comunidades y organizaciones no gubernamentales que buscan alcanzar resultados con beneficios tanto para la conservación como para la mitigación de la pobreza. A pesar de que múltiples ECI suelen implementarse simultáneamente, es raro que se tomen en cuenta las posibles interacciones positivas (sinergías) o negativas (trade-offs) durante el diseño, la implementación y la evaluación de estos programas. En búsqueda de un uso más deliberado y efectivo de las ECI, examinamos las interacciones entre cuatro estrategias conocidas: reservas de la biósfera (RB), áreas protegidas voluntarias (APV), pagos por servicios ambientales (PSA) y el manejo comunitario de los bosques (MCB). Mediante un estudio de caso comparativo analizamos las interacciones entre las ECI agrupadas espacial o temporalmente implementadas en tierras con administración y propiedad comunal en tres regiones con diferencias ecológicas y socioeconómicas en México. Nuestros métodos de investigación combinaron el análisis de políticas con datos recopilados mediante la observación participativa, entrevistas semiestructuradas (n = 78) y grupos focales (n = 5) con funcionarios del gobierno, implementadores y participantes involucrados en las ECI de 28 comunidades. A pesar de las diferencias significativas entre las regiones en las que se implementaron estas ECI, descubrimos que los actores clave en cada nivel de participación percibieron de manera generalizada las interacciones entre las ECI como sinérgicas. Los programas de PSA fueron percibidos como algo que fortalece a las áreas protegidas mediante la reducción de la pérdida de la cobertura forestal dentro y fuera de las RB, el fomento de las actitudes a favor de la conservación y el estímulo al establecimiento de las APV. Las comunidades que invirtieron los ingresos por PSA en el MCB expresaron su motivación para conservar los bosques más allá de la duración de los programas de PSA y el MCB en zonas de amortiguamiento fue percibido como un factor de fortalecimiento de las RB mediante el mantenimiento de la cobertura forestal y la generación de ingresos para las comunidades. También identificamos los factores sociales y ambientales importantes que pueden influir sobre estos efectos de interacción entre las ECI. Con base en estos hallazgos, recomendamos un estudio más profundo de las interacciones entre las ECI y un diseño de políticas intencionalmente complementario para maximizar los resultados sociales y ambientales positivos.