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Widespread use of antiretroviral drugs for pregnant/breastfeeding females with human immunodeficiency virus (HIV) has led to declining vertical transmission. Despite being HIV-uninfected, the increasing number of children who are HIV-exposed and uninfected (CHEU) often present with developmental alterations. We review seminal and recent evidence on the neurological development of CHEU and associations with early life HIV/antiretroviral exposure. Our conceptual model highlights the numerous exposures and universal risk factors for CHEU developmental disorders. Early studies suggest a significant association between HIV exposure and neurological abnormalities, varying according to the burden of HIV-specific exposures and other risk factors. More recent observations from the modern era are inconsistent, although some studies suggest specific antiretrovirals may adversely affect neurological development of CHEU. As the CHEU population continues to grow, alongside simultaneous increases in types and combinations of antiretrovirals used in pregnancy, long-term monitoring of CHEU is necessary for understanding the effects of HIV/antiretroviral exposure on CHEU developmental outcomes. What this paper adds Evidence on the neurological development of children who are human immunodeficiency virus (HIV)-exposed and uninfected (CHEU) is synthesized. Comparisons are made to children who are HIV-unexposed, across treatment eras and settings, and by antiretroviral drug regimens and drug classes. CHEU exposures are complex and include HIV-specific and universal risk factors which may affect development during the early years of life., (© 2021 The Authors. Developmental Medicine & Child Neurology published by John Wiley & Sons Ltd on behalf of Mac Keith Press.)

Estimates of global economic damage caused by carbon dioxide (CO 2 ) emissions can inform climate policy 1-3 . The social cost of carbon (SCC) quantifies these damages by characterizing how additional CO 2 emissions today impact future economic outcomes through altering the climate 4-6 . Previous estimates have suggested that large, warming-driven increases in energy expenditures could dominate the SCC 7,8 , but they rely on models 9-11 that are spatially coarse and not tightly linked to data 2,3,6,7,12,13 . Here we show that the release of one ton of CO 2 today is projected to reduce total future energy expenditures, with most estimates valued between -US$3 and -US$1, depending on discount rates. Our results are based on an architecture that integrates global data, econometrics and climate science to estimate local damages worldwide. Notably, we project that emerging economies in the tropics will dramatically increase electricity consumption owing to warming, which requires critical infrastructure planning. However, heating reductions in colder countries offset this increase globally. We estimate that 2099 annual global electricity consumption increases by about 4.5 exajoules (7 per cent of current global consumption) per one-degree-Celsius increase in global mean surface temperature (GMST), whereas direct consumption of other fuels declines by about 11.3 exajoules (7 per cent of current global consumption) per one-degree-Celsius increase in GMST. Our finding of net savings contradicts previous research 7,8 , because global data indicate that many populations will remain too poor for most of the twenty-first century to substantially increase energy consumption in response to warming. Importantly, damage estimates would differ if poorer populations were given greater weight 14 ., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objectives: To examine the health effects of the Supplemental Nutritional Assistance Program (SNAP) and the differential impact of SNAP across race/ethnicity among older adults., Data Source/study Setting: 2008-2013 Medical Expenditure Panel Survey, a nationally representative population-based complex sample survey., Study Design: A difference-in-regression-discontinuity (DRD) design is used to assess the impacts of SNAP on diet-related disease morbidity. The primary outcomes were the prevalence rate of hypertension, coronary heart disease, stroke, diabetes, and cancer. We also conducted supplemental analysis to examine potential co-occurring trends in medical utilization., Data Collection/extraction Methods: Data are publicly available., Principal Findings: In the full sample, SNAP eligibility was associated with a significant decline in diabetes (-3.71 percentage points [pp]; P < .05). Non-Hispanic (NH) White respondents reported trends similar to the full sample; however, NH Black respondents reported large declines in hypertension (-13.95 pp; P < .01) and Hispanic respondents reported declines in the prevalence of angina (-6.94 pp; P < .05) and stroke (-4.48 pp; P < .05)., Conclusions: Supplemental Nutritional Assistance Program eligibility was associated with the reduced prevalence of diet-related disease among older adults. These observed declines in the prevalence of diet-related disease do not appear to be attributable to increased medical visits or spending on medical services and prescriptions., (© 2021 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Poverty is a chronic stressor associated with disruptions in psychophysiological development during adolescence. This study examined associations of chronic poverty and income changes experienced from pre- to mid-adolescence with hypothalamic-pituitary-adrenal (HPA) axis stress responses in late adolescence. Participants (N = 229) were adolescents of Mexican-origin (48.7% female). Household income (converted to income-to-needs ratios) was assessed annually when children were 10-16 years old. At 17 years, adolescents completed Cyberball, a social exclusion simulation task while undergoing a functional magnetic resonance imaging scan. Saliva samples were collected prior to and five times over a 50-minute period following the scan, from which salivary cortisol was assayed. Results showed that differential trajectories of poverty from ages 10-16 predicted HPA axis activity at age 17. Relative to others, distinct HPA suppression (hyporeactivity) was demonstrated by youth who started adolescence in deep poverty and were still living in poverty at age 16 despite experiencing some income gains. Youth from more economically secure families evinced typical cortisol increases following the lab stressor. These results suggest that subsequent HPA functioning varies as a function of economic status throughout adolescence, and that efforts to increase family income may promote healthy HPA functioning for youths in the most impoverished circumstances., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Understanding why different nations have different homicide and suicide rates has been of interest to scholars, policy makers and the general public for years. Multiple theories have been offered, related to the economy, presence of guns and even exposure to violence in video games. In the current study, several factors were considered in combination across a sample of 92 countries. These included income inequality (Gini index), Human Capital Index (education and employment), per capita gun ownership and per capita expenditure on video games. Results suggest that economic factors primarily were related to homicide and suicide cross-nationally. Video game consumption was not a major indicative factor (other than a small negative relationship with homicides). More surprisingly, per capita gun ownership was not an indicator factor cross-nationally. The results suggest that a focus on economic factors and income inequality are most likely to bear fruit regarding reduction of violence and suicide., (© 2021 International Union of Psychological Science.)

Background: Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies., Objective: The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors., Research Design: Multicenter retrospective cohort study examining COVID-19 in-hospital mortality., Subjects: Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers., Measures: The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects., Results: Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality., Conclusions: Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities., Competing Interests: C.M.B. reported receiving institutional grants from Independent Grants for Learning and Change (Pfizer) for an unrelated nonbranded smoking cessation project during the conduct of the study. L.E.L. is a consultant for IVD Vision for an unrelated COVID-19 project on molecular-based testing. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The importance of social and economic capital as predictors of health is widely documented, yet the complexity of interactions between them and effects on older people's health is still unclear. Combining the material and psychosocial explanations of health, this study explores the potential interactions between social and economic capital in influencing older adults' health in urban and rural China., Methods: Using data from the China Family Panel Survey, physical and mental health in 2018 were regressed on social and economic capital indicators in 2016, controlling for sociodemographic characteristics of 3535 respondents aged 65 and older. Rothman's synergy index was calculated to investigate potential interaction effects., Results: Economic hardships were significantly related to both self-reported health and mental health. Neighborhood cohesion and social participation were significantly associated with mental health for all, bonding trust was significantly associated with mental health for urban older people. We found no significant associations between social capital components and self-reported health. There was an interaction effect between low neighborhood cohesion and economic hardships, and between low social participation and economic hardships, creating an increased burden of poor mental health. The interaction effect between low bonding trust and economic hardships on mental health was apparent only among urban older people., Conclusions: Geographical settings are important factors in the complexity between social and economic capital in affecting older health. Intervention efforts directed towards reducing simultaneously multiple dimensions of deprivation, such as poverty, social exclusion, social isolation, could be helpful in improving older people's health. In materially deprived places, policies to promote health equity by improving social capital but without eliminating poverty may be less effective., (© 2021. The Author(s).)

Advances in remote sensing and machine learning enable increasingly accurate, inexpensive, and timely estimation of poverty and malnutrition indicators to guide development and humanitarian agencies' programming. However, state of the art models often rely on proprietary data and/or deep or transfer learning methods whose underlying mechanics may be challenging to interpret. We demonstrate how interpretable random forest models can produce estimates of a set of (potentially correlated) malnutrition and poverty prevalence measures using free, open access, regularly updated, georeferenced data. We demonstrate two use cases: contemporaneous prediction, which might be used for poverty mapping, geographic targeting, or monitoring and evaluation tasks, and a sequential nowcasting task that can inform early warning systems. Applied to data from 11 low and lower-middle income countries, we find predictive accuracy broadly comparable for both tasks to prior studies that use proprietary data and/or deep or transfer learning methods., Competing Interests: The authors have declared that no competing interests exist.

Background: Low socioeconomic status deemed by income-based measures is a risk factor for depression. Material hardship is commonly used as a multidimensional socioeconomic indicator to identify the struggles that low-income households encounter that are not captured by conventional income-based measures. The aim of this study was to examine the effect of material hardship on depression., Methods: We used wave 3 (2008) to wave 12 (2017) panel data collected by the Korea Welfare Panel Study. The material hardship measure included six dimensions: food, housing, medical care, paying utility bills, education, and financial hardship. Depression was measured using the Center for Epidemiologic Studies Depression Scale (CESD-11). A generalised estimating equation model was applied to test the causal association between material hardship and log transferred CESD-11., Results: The first time point comprised 3,866 participants. Those who continually experienced material hardship had higher depression scores (male: β = 2.82, female: β = 3.98, p-value: < .0001). Food hardship was the most critical risk factor (male: β = 3.29, female: β = 4.05, p-value: < .0001)., Conclusions: Material hardship is associated with increased risk of depression, especially food hardship. We should consider guaranteeing food security, and community and policy makers should consider material hardship in their approach when identifying low-income populations at high risk for depression., (© 2021. The Author(s).)

Importance: Despite much higher health care expenditure than comparable countries, striking racial and ethnic disparities exist in obstetric outcomes in the United States. A multifaceted exploration of the factors influencing these disparities, including the legacy of structural racism, is important to improve health outcomes for all., Objective: To characterize the association of the historic racially discriminatory home loan practice of redlining with disparities in modern obstetric outcomes., Design, Setting, and Participants: In this retrospective cohort study of a 9-county birth certificate database in the Finger Lakes region of New York state from 2005 to 2018, modern obstetric outcomes were matched with regions classified by the federal government for mortgage loan servicing based on racially discriminatory criteria from the 1940 Home Owners' Loan Corporation map (HOLC; also known as the redline map). Patients with a live birth recorded in the data system with a recorded home zip code within the historic HOLC categories were included. Data were analyzed from July to December 2019., Exposure: Regions previously categorized by historic, racially discriminatory criteria., Main Outcomes and Measures: Each HOLC area was analyzed for the primary outcome of preterm birth and secondary outcomes of obstetric and medical complications, with logistic regression to address regional and patient-level covariates., Results: From 2005 until 2018, there were 64 804 live births within the 15 zip codes overlaying historic HOLC regions. Prevalence of preterm birth increased with decreasing HOLC categories, from the lowest overall preterm birth rate of 217 of 2873 births (7.55%) in the zip code historically defined as "Best" or "Still Desirable" and the highest overall preterm birth rate of 427 of 3449 births (12.38%) in the zip code historically defined as "Hazardous." These associations with preterm birth remained significant in logistic regression controlling for poverty levels and educational attainment (adjusted odds ratio, 1.46; 95% CI, 1.08-1.97) and parental race (adjusted odds ratio, 1.38; 95% CI, 1.25-1.53)., Conclusions and Relevance: In this cohort study, the linkage of historic and modern community data sets with an obstetric data set offered the opportunity to characterize modern obstetric disparities associated with a system of historic inequity. The persistence of these findings after correcting for contemporary community socioeconomic characteristics suggest potential influences of a system of profound structural inequity that ripple forward in time, with impacts that extend beyond measurable socioeconomic inequity.

Objective: Higher mortality among full-term infants (term infant deaths) contributes to disparities in infant mortality between the United States and other developed countries. We examined differences in the causes of term infant deaths across county poverty levels and urban-rural classification to understand underlying mechanisms through which these factors may act., Methods: We linked period birth/infant death files for 2012-2015 with US Census poverty estimates and county urban-rural classifications. We grouped the causes of term infant deaths as sudden unexpected death in infancy (SUDI), congenital malformations, perinatal conditions, and all other causes. We computed the distribution and relative risk of overall and cause-specific term infant mortality rates (term IMRs) per 1000 live births and 95% CIs for county-level factors., Results: The increase in term IMR across county poverty and urban-rural classification was mostly driven by an increase in the rate of SUDI. The relative risk of term infant deaths as a result of SUDI was 1.6 (95% CI, 1.5-1.8) times higher in medium-poverty counties and 2.3 (95% CI, 1.2-2.5) times higher in high-poverty counties than in low-poverty counties. Cause-specific IMRs of congenital malformations, perinatal conditions, and death from other causes did not differ by county poverty level. We found similar trends across county urban-rural classification. Sudden infant death syndrome was the main cause of SUDI across both county poverty levels and urban-rural classifications, followed by unknown causes and accidental suffocation and strangulation in bed., Conclusions: Interventions aimed at reducing SUDI, particularly in high-poverty and rural areas, could have a major effect on reducing term IMR disparities between the United States and other developed countries.

Objective: Ensuring access to sufficient foods at all times is critical to veterans' health and well-being. Food insecurity has not been well explored in the veteran population. We examined the prevalence and predictors of food insecurity among low-income veterans, because the highest rates of food insecurity are among low-income households. We also examined rates of Supplemental Nutrition Assistance Program (SNAP) participation among subgroups at the highest risk of food insecurity., Methods: We used univariate analyses and 2011-2017 National Health Interview Survey (NHIS) data on veterans aged ≥21 with family incomes <200% of the federal poverty level to estimate the prevalence of food insecurity. We used bivariate analyses to identify correlates of food insecurity and estimate SNAP participation rates among subgroups of low-income veterans. Percentages were weighted using NHIS survey weights., Results: Of 5146 low-income veterans, 22.5% reported being food insecure in the previous month. Food insecurity was significantly associated with being aged <65 (33.0% aged 45-64 and 29.7% aged 21-44) compared with 15.0% and 6.4% among veterans aged 65-74 and ≥75, respectively ( P < .001); unemployed compared with employed or not in the labor force (39.4%, 22.7%, and 20.2%, respectively; P < .001); in fair or poor health compared with good, very good, or excellent heath (31.8% vs 18.2%; P < .001); and having experienced serious psychological distress in the past month (56.3%) compared with not having experienced such distress (19.7%; P < .001). Although overall SNAP participation among low-income veterans was estimated to be 27.0%, participation rates were highest among veterans who had experienced serious psychological distress (44.1%), were unemployed (39.2%), and were renting their home (39.0%)., Conclusions: Some low-income veterans are at greater risk of food insecurity than other veterans. Postseparation programs, civilian support services, and veterans' health providers should be aware of the characteristics that place veterans at highest risk of food insecurity.

In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (persons aged 18-64 years) with incomes up to 138% of the federal poverty level. To our knowledge, the association of Medicaid expansion with suicide, a leading cause of death in the United States, has not been examined. We used 2005-2017 data from the National Violent Death Reporting System to analyze suicide mortality in 8 Medicaid expansion states and 7 nonexpansion states. Using a difference-in-differences approach, we examined the association between Medicaid expansion and the rate of suicide death (number of deaths per 100,000 population) among nonelderly adults. After adjustment for state-level confounders, Medicaid expansion states had 1.2 fewer suicide deaths (β = -1.2, 95% confidence interval: -2.5, 0.1) per 100,000 population per year during the postexpansion period than would have been expected if they had followed the same trend in suicide rates as nonexpansion states. Medicaid expansion was associated with reductions in suicide rates among women, men, persons aged 30-44 years, non-Hispanic White individuals, and persons without a college degree. Medicaid expansion was not associated with a change in suicide rates among persons aged 18-29 or 45-64 years or among non-White or Hispanic individuals. Overall, Medicaid expansion was associated with reductions in rates of suicide death among nonelderly adults. Further research on inequities in Medicaid expansion benefits is needed., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Social scientists identify two core functions of modern welfare states as redistribution across (a) socio-economic status groups (Robin Hood) and (b) 'the lifecycle' (the piggy bank). But what is the relative importance of these functions? The answer has been elusive, as the piggy bank is metaphorical. The intra-personal time-travel of resources it implies is based on non-quid-pro-quo transfers. In practice, 'lifecycle redistribution' must operate through inter-age-group resource reallocation in cross-section. Since at any time different birth cohorts live together, 'resource-productive' working-aged people are taxed to finance consumption of 'resource-dependent' younger and older people. In a novel decomposition analysis, we study the joint distribution of socio-economic status, age, and respectively (a) all cash and in-kind transfers ('benefits'), (b) financing contributions ('taxes'), and (c) resulting 'net benefits,' on a sample of over 400,000 Europeans from 22 EU countries. European welfare states, often maligned as ineffective Robin Hood vehicles riddled with Matthew effects, are better characterized as inter-age redistribution machines performing a more important second task rather well: lifecycle consumption smoothing. Social policies serve multiple goals in Europe, but empirically they are neither primarily nor solely responsible for poverty relief and inequality reduction., Competing Interests: The authors have declared that no competing interests exist.

Objective: To investigate the relationship between late-life duration of poverty exposure and cognitive function and decline among older adults in China., Methods: Data were from 3,209 participants ≥64 years of age in the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Duration of poverty, defined according to urban and rural regional standards from the China Statistical Yearbook, was assessed according to annual household income from 2005 to 2011 (never in poverty; one-third of the period in poverty; two-thirds or more of the period in poverty). Cognitive function was measured by the Chinese Mini-Mental State Examination (CMMSE) from 2011 to 2018. We used attrition-weighted, multivariable mixed-effects Tobit regression to examine the association of duration of poverty with cognitive function and rate of decline., Results: A total of 1,162 individuals (36.21%) were never in poverty over the period from 2005 to 2011; 1,172 (36.52%) were in poverty one-third of the period; and 875 (27.27%) were in poverty two-thirds or more of the period. A longer poverty duration was associated with lower subsequent CMMSE scores with a dose-response relationship (one-third vs never in poverty: β = -0.98; 95% confidence interval -1.61 to -0.35; two-thirds or more vs never in poverty: β = -1.55; 95% confidence interval -2.29 to -0.81). However, a longer duration of poverty was associated with a slower rate of CMMSE score decline over time from 2011 to 2018., Conclusion: These findings provide valuable evidence for the role of cumulative late-life poverty in relation to cognitive health among older adults in a rapidly urbanizing and aging middle-income country. Our findings may support a compensation hypothesis for cognitive reserve in this setting., (© 2021 American Academy of Neurology.)

Background: The impact of social determinants of health on children with polyarticular juvenile idiopathic arthritis (pJIA) is poorly understood. Prompt initiation of treatment for pJIA is important to prevent disease morbidity; however, a potential barrier to early treatment of pJIAs is delayed presentation to a pediatric rheumatologist. We examined the impact of community poverty level, a key social determinant of health, on time from patient reported symptom onset to first pediatric rheumatology visit among pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry., Methods: This is a cohort study of pJIA patients in the CARRA registry who lived in the United States from July 2015-February 2020. The primary exposure was community poverty level derived by geocoding patient addresses. The primary outcome was time to first rheumatology appointment. Kaplan-Meier analysis was performed to analyze time to first rheumatologist visit, stratified by community poverty and family income. Log-rank tests were used to identify differences between groups. Adjusted cox proportional-hazards models were used to determine the relationship between community poverty level and time from onset of disease symptoms to date first seen by rheumatologist., Results: A total of 1684 patients with pJIA meeting study inclusion and exclusion criteria were identified. Median age of onset of pJIA was 7 years (IQR 3, 11), 79% were female, 17.6% identified as minority race and/or ethnicity, and 19% were from communities with ≥20% community poverty level. Kaplan-Meier analysis by community poverty level (< 20% vs ≥20%) yielded no significant differences with time to initial presentation to a pediatric rheumatologist (p = 0.6). The Cox proportional hazards model showed that patients with ≥20% community poverty level were 19% less likely (adjusted HR 0.81, 95% CI 0.67-0.99, p = 0.038) to be seen by a rheumatologist compared to patients with < 20% community poverty level, at the same time point, after adjusting for sex, race/ethnicity, insurance, education level, morning stiffness, RF status, and baseline CHAQ., Conclusion: In this study of pJIA patients in the CARRA registry, increased community poverty level is associated with longer time to presentation to a pediatric rheumatologist after symptom onset., (© 2021. The Author(s).)

Introduction: In the last decade, survival of people living with HIV (PLHIV) has dramatically increased due wide availability of effective antiretroviral therapy. However, PLHIV remain at a comparatively higher risk of non-communicable comorbidities. We sought to determine the burden of COPD and its associations in an urban tertiary HIV clinic in Uganda., Methods and Findings: HIV-infected adults attending the Makerere University Joint AIDS program; aged ≥30 years without acute ailments were screened for COPD using study questionnaires and spirometry (post-bronchodilator FEV1/FVC<0.7). We determined its prevalence and association with demographic characteristics, body mass index (BMI) and known risk factors. Of 288 participants enrolled, 177 (61%) were female; 253 (88%) were from urban residences, median age was 45 years (IQR: 39-51), 71(25%) were 'ever' smokers, 284(99%) reported biomass fuel use and 72(25%) had a history of tuberculosis. All except 1 participant were on antiretroviral therapy, median current CD4 (cells/mm3) was 558 (IQR 402-753) and 275(96%) were virologically suppressed. Nearly half (130/288, 45%) had recurrent respiratory symptoms. The prevalence of COPD was 3.1% (9/288) [95% CI: 1.63-5.92]. COPD was associated with: previous tuberculosis, (adjusted odds ratio (AOR): 6.36, [95% CI 1.64-35.84], P = 0.036), self-reported chronic shortness of breath (AOR: 9.06, [95% CI 1.34-61.10], P = 0.024) and a BMI <21 Kg/m2 (AOR: 10.42 [95% CI: 1.61-100.00], P = 0.013)., Conclusion: In this HIV population, COPD prevalence was low and was associated with previous tuberculosis, self-reported chronic shortness of breath and BMI <21 Kg/m2., Competing Interests: The authors have declared that no competing interests exist

Objectives: Mexico is among the countries in Latin America hit hardest by coronavirus disease 2019 (COVID-19). A large proportion of older adults in Mexico have high prevalence of multimorbidity and live in poverty with limited access to health care services. These statistics are even higher among adults living in rural areas, which suggest that older adults in rural communities may be more susceptible to COVID-19. The objectives of the article were to compare clinical and demographic characteristics for people diagnosed with COVID-19 by age group, and to describe cases and mortality in rural and urban communities., Method: We linked publicly available data from the Mexican Ministry of Health and the Census. Municipalities were classified based on population as rural (<2,500), semirural (≥2,500 and <15,000), semiurban (≥15,000 and <100,000), and urban (≥100,000). Zero-inflated negative binomial models were performed to calculate the total number of COVID-19 cases, and deaths per 1,000,000 persons using the population of each municipality as a denominator., Results: Older adults were more likely to be hospitalized and reported severe cases, with higher mortality rates. In addition, rural municipalities reported a higher number of COVID-19 cases and mortality related to COVID-19 per million than urban municipalities. The adjusted absolute difference in COVID-19 cases was 912.7 per million (95% confidence interval [CI]: 79.0-1746.4) and mortality related to COVID-19 was 390.6 per million (95% CI: 204.5-576.7)., Discussion: Urgent policy efforts are needed to mandate the use of face masks, encourage handwashing, and improve specialty care for Mexicans in rural areas., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: As epidemiological data on child mental health in low- and middle-income countries are limited, a large-scale survey was undertaken to estimate the prevalence and amount of child emotional and behavioral problems (EBP) in Nepal as reported by the parents., Methods: 3820 schoolchildren aged 6-18 years were selected from 16 districts of the three geographical regions of Nepal, including rural, semi-urban and urban areas. We used the Nepali version of the Child Behavior Checklist (CBCL)/6-18 years as screening instrument. Comparisons of child problems between genders and between the seven largest castes and ethnic groups were carried out by analysis of variance. Prevalence was computed based on American norms., Results: Adjusted prevalence of Total Problems was 18.3% (boys: 19.1%; girls:17.6%). The prevalence of internalizing problems was higher than externalizing problems. The mean scores of Total, Externalizing, and Internalizing problems were 29.7 (SD 25.6), 7.7 (SD 8.0), and 9.1 (SD 8.1), respectively. The Khas Kaami (Dalit) group scored the highest, and the indigenous Tharu group scored the lowest on all scales. In the Mountains and Middle Hills regions, problem scores were higher in the rural areas, whereas in the Tarai region, they were higher in the urban areas., Conclusion: The prevalence and magnitude of emotional and behavioral problems in Nepali children were found to be high compared to findings in meta-analyses worldwide. Problem scores varied according to gender, castes /ethnic groups, and living areas. Our findings highlight the need for a stronger focus on child mental problems in a low-and middle-income country like Nepal., Competing Interests: The authors have declared that no competing interests exist.

Importance: Food insecurity is associated with a less healthy diet. The Supplemental Nutrition Assistance Program (SNAP) is associated with reduced food insecurity, but benefit levels may be insufficient for beneficiaries to afford healthy foods., Objective: To evaluate whether participation in SuperSNAP, a program that provides an additional $40 per month for the purchase of fruits and vegetables with no added sugar, sodium, or fat to SNAP beneficiaries, is associated with changes in food purchasing., Design, Setting, and Participants: This longitudinal cohort study used data from transaction records of a large supermarket chain with approximately 500 stores located across North Carolina from October 2019 to April 2020. Participants were SNAP beneficiaries., Exposure: SuperSNAP participation., Main Outcomes and Measures: Monthly spending on all fruits, vegetables, legumes, and nuts (primary outcome); spending on less healthy food categories; and spending on sugar-sweetened beverages as 1 category of less healthy foods. Monthly data on purchases by SNAP beneficiaries before and during SuperSNAP participation were compared with data from SNAP beneficiaries not enrolled in the program who shopped at the same stores. Overlap weighting (a propensity score-based method) was used to account for confounding, and linear mixed-effects models were fitted with random effects to account for repeated measures and clustering by store., Results: The study included 667 SuperSNAP participants and 33 246 SNAP beneficiaries who did not use SuperSNAP but shopped in the same stores; 436 SuperSNAP participants had preintervention data and were included in the main analysis. SuperSNAP participation was associated with increased monthly purchases of fruits, vegetables, nuts, and legumes ($31.84; 95% CI, $31.27-$32.42; P < .001; 294.52 oz; 95% CI, 288.84-300.20 oz; P < .001). Only a small increase in spending on less healthy food categories compared with the SNAP beneficiaries who did not use SuperSNAP ($1.60; 95% CI, $0.67-$2.53; P < .001) was observed. As total spending increased, the proportion of total food and beverage spending on less healthy foods significantly decreased (difference, 4.51%; 95% CI, 4.27%-4.74%; P < .001). Monthly spending on sugar-sweetened beverages decreased (difference, $1.83; 95% CI, $1.30-$2.36; P < .001)., Conclusions and Relevance: In this cohort study, participation in SuperSNAP was associated with meaningful increases in healthy food purchasing. Subsequent studies should investigate whether healthy food incentive programs improve health outcomes.

Importance: Evidence on the suitability of anthropometric failure (ie, stunting, underweight, and wasting) as a stand-alone measure of child undernutrition can inform global and national nutrition and health agendas., Objective: To provide a comprehensive estimate of the prevalence of child undernutrition by evaluating both dietary and anthropometric measures simultaneously across 55 low- and middle-income countries., Design, Setting, and Participants: This was a cross-sectional study that used Demographic and Health Surveys program data from July 2009 to January 2019, to allocate children into dietary and anthropometric failure categories. Nationally representative household surveys were conducted in 55 low- and middle-income countries. Participants included children aged 6 to 23 months who were born singleton and had valid anthropometric measures as well as available 24-hour food intake recollection. Data analysis was conducted from August 23 to October 22, 2020., Exposures: Two factors were considered to allocate children into the respective categories. Dietary failure was based on the World Health Organization standards for minimum dietary diversity. Anthropometric failure was constructed using the World Health Organization child growth reference standard z score for stunted growth, muscle wasting, and less than average weight for age., Main Outcomes and Measures: Dietary and anthropometric failures were cross-tabulated, which yielded 4 potential outcomes: dietary failure only, anthropometric failure only, both failures, and neither failure. Total child populations for each category were extrapolated from United Nations population estimates., Results: Of the 162 589 children (median age [range], 14 months [6-23 months]; 83 467 boys [51.3%]; 78 894 Asian children [48.5%]) in our sample, 42.9% of children had dietary failure according to the standard World Health Organization definition without being identified as having anthropometric failures. In all, 34.7% had both failures, 42.9% had dietary failure only, 8.3% had anthropometric failure only, and 14.1% had neither failure. Dietary and anthropometric measures were discordant for 51.2% of children; these children had nutritional needs identified by only 1 of the 2 measures. Dietary failure doubled the proportion of children in need of dietary interventions compared with anthropometry alone (43%). A total of 45.3 million additional children who experienced undernutrition in these 55 countries were not captured through the evaluation of anthropometric failures only. These results were consistent across geographic regions., Conclusions and Relevance: The results of this cross-sectional study suggest that the current standard of measuring child undernutrition by estimating the prevalence of anthropometric failure should be complemented with dietary and food-based measures. Anthropometry alone may fail to identify many children who have insufficient dietary intake.

Importance: Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid., Objective: To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births., Design, Setting, and Participants: This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021., Exposures: Medicaid coverage of prenatal care., Main Outcomes and Measures: Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy., Results: The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points])., Conclusions and Relevance: This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.

Women make up the large majority of workers in global supply chains, especially factories in the apparel supply chain. These workers face significant inequalities in wages, workplace hazards, and a special burden of gender-based violence and harassment. These "normal" conditions have been compounded by the impact of the COVID-19 pandemic, which has exacerbated long-standing structural inequities. Decades of well-financed "corporate social responsibility" programs have failed because they do not address the underlying causes of illegal and abusive working conditions. New initiatives in the past half-decade offer promise in putting the needs and rights of workers front and center. Occupational health and safety professionals can assist in the global effort to improve working and social conditions, and respect for the rights and dignity of women workers, through advocacy and action on the job, in their professional associations, and in society at large.

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Provisional records from the US Centers for Disease Control and Prevention (CDC) through July 2020 indicate that overdose deaths spiked during the early months of the COVID-19 pandemic, yet more recent trends are not available, and the data are not disaggregated by month of occurrence, race/ethnicity, or other social categories. In contrast, data from emergency medical services (EMS) provide a source of information nearly in real time that may be useful for rapid and more granular surveillance of overdose mortality., Objective: To describe racial/ethnic, social, and geographic trends in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through December 2020 and assess the concordance with CDC-reported provisional total overdose mortality through May 2020., Design, Setting, and Participants: This cohort study included more than 11 000 EMS agencies in 49 US states that participate in the National EMS Information System and 83.7 million EMS activations in which patient contact was made., Exposures: Year and month of occurrence of overdose-associated cardiac arrest; patient race/ethnicity; census region and division; county-level urbanicity; and zip code-level racial/ethnic composition, poverty, and educational attainment., Main Outcomes and Measures: Overdose-associated cardiac arrests per 100 000 EMS activations with patient contact in 2020 were compared with a baseline of values from 2018 and 2019. Aggregate numbers of overdose-associated cardiac arrests and percentage increases were compared with provisional total mortality in CDC records from rolling 12-month windows with end months spanning January 2018 through July 2020., Results: Among 33.4 million EMS activations in 2020, 16.8 million (50.2%) involved female patients and 16.3 million (48.8%) involved non-Hispanic White individuals. Overdose-associated cardiac arrests were elevated by 42.1% nationally in 2020 (42.3 per 100 000 EMS activations at baseline vs 60.1 per 100 000 EMS activations in 2020). The highest percentage increases were seen among Latinx individuals (49.7%; 38.8 per 100 000 activations at baseline vs 58.1 per 100 000 activations in 2020) and Black or African American individuals (50.3%; 21.5 per 100 000 activations at baseline vs 32.3 per 100 000 activations in 2020), people living in more impoverished neighborhoods (46.4%; 42.0 per 100 000 activations at baseline vs 61.5 per 100 000 activations in 2020), and the Pacific states (63.8%; 33.1 per 100 000 activations at baseline vs 54.2 per 100 000 activations in 2020), despite lower rates at baseline for these groups. The EMS records were available 6 to 12 months ahead of CDC mortality figures and showed a high concordance (r = 0.98) for months in which both data sets were available. If the historical association between EMS-observed and total overdose mortality holds true, an expected total of approximately 90 632 (95% CI, 85 737-95 525) overdose deaths may eventually be reported by the CDC for 2020., Conclusions and Relevance: In this cohort study, records from EMS agencies provided an effective manner to rapidly surveil shifts in US overdose mortality. Unprecedented overdose deaths during the pandemic necessitate investments in overdose prevention as an essential aspect of the COVID-19 response and postpandemic recovery. This is particularly urgent for more socioeconomically disadvantaged and racial/ethnic minority communities subjected to the compounded burden of disproportionate COVID-19 mortality and rising overdose deaths.

Changes in school meal programs can affect well-being of millions of American children. Since 2014, high-poverty schools and districts nationwide had an option to provide universal free meals (UFM) through the Community Eligibility Provision (CEP). The COVID-19 pandemic expanded UFM to all schools in 2020-2022. Using nationally representative data from the Early Childhood Longitudinal Study: Kindergarten Class of 2010-2011, we measured CEP effects on school meal participation, attendance, academic achievement, children's body weight, and household food security. To provide plausibly causal estimates, we leveraged the exogenous variation in the timing of CEP implementation across states and estimated a difference-in-difference model with child random effects, school and year fixed effects. On average, CEP participation increased the probability of children's eating free school lunch by 9.3% and daily school attendance by 0.24 percentage points ( p < 0.01). We find no evidence that, overall, CEP affected body weight, test scores and household food security among elementary schoolchildren. However, CEP benefited children in low-income families by decreasing the probability of being overweight by 3.1% ( p < 0.05) and improving reading scores of Hispanic children by 0.055 standard deviations. UFM expansion can particularly benefit at-risk children and help improve equity in educational and health outcomes.

Background: More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level., Method: American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138-400 % and (3) > 400 % federal poverty level (FPL)., Results: Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138-400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated., Conclusion: Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured., (© 2021. The Author(s).)

Snacking contributes a significant portion of adolescents' daily energy intake and is associated with poor overall diet and increased body mass index. Adolescents from low socioeconomic status (SES) households have poorer snacking behaviors than their higher-SES counterparts. However, it is unclear if the types of food/beverages and nutrients consumed during snacking differ by SES among adolescents. Therefore, this study examines SES disparities in the aforementioned snacking characteristics by analyzing the data of 7132 adolescents (12-19 years) from the National Health and Nutrition Examination Survey 2005-2018. Results reveal that adolescents from low-income households (poverty-to-income ratio (PIR) ≤ 1.3) have lower odds of consuming the food/beverage categories "Milk and Dairy" (aOR: 0.74; 95% CI: 0.58-0.95; p = 0.007) and "Fruits" (aOR: 0.62, 95% CI: 0.50-0.78; p = 0.001) as snacks and higher odds of consuming "Beverages" (aOR: 1.45; 95% CI: 1.19-1.76; p = 0.001) compared to those from high-income households (PIR > 3.5). Additionally, adolescents from low- and middle-income (PIR > 1.3-3.5) households consume more added sugar (7.98 and 7.78 g vs. 6.66 g; p = 0.012, p = 0.026) and less fiber (0.78 and 0.77 g vs. 0.84 g; p = 0.044, p = 0.019) from snacks compared to their high-income counterparts. Future research is necessary to understand factors that influence snacking among adolescents, and interventions are needed, especially for adolescents from low-SES communities.

Background Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out-of-pocket healthcare costs on patients with HF and their families. Methods and Results In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out-of-pocket healthcare expenditures included yearly care-specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden-total out-of-pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%-a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%-0.60%) of all families nationally. The overall mean annual out-of-pocket healthcare expenses were $4423 (95% CI, $3908-$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%-18%) of families experienced a high burden and 5% (95% CI, 3%-6%) experienced a catastrophic burden. Among the two-fifths of families considered low income, 24% (95% CI, 18%-30%) experienced a high financial burden, whereas 10% (95% CI, 6%-14%) experienced a catastrophic burden. Low-income families had 4-fold greater risk-adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3-6.6), and 14-fold greater risk-adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1-39.5) compared with middle/high-income families. Conclusions Patients with HF and their families experience large out-of-pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low-income families.

Competing Interests: The authors have no funding or conflicts of interest to disclose.

Objective: To investigate the individual and cumulative impact of childhood and adulthood adversity on allostatic load (AL) burden., Method: Retrospective cross-sectional study design involving 4,165 participants from the first wave of The Irish Longitudinal study on Ageing (TILDA). AL was operationalized using 12 biomarkers across four physiological systems (cardiovascular, metabolic, renal, and immune). Measures of psychosocial adversity included poverty, abuse, loss, and illness. Negative binomial regression models estimated the relationship of individual adversities and a cumulative count of adversities with AL burden, controlling for age and sex. Multivariable models adjusted additionally for a range of other sociodemographic and lifestyle factors., Results: Childhood poverty, childhood physical abuse, and having a spouse/partner/child experience a life-threatening illness/accident were associated with 10% (95% CI [1.04, 1,16]), 10% (95% CI [1.01, 1.18]), and 6% (95% CI [1.01, 1.11]) greater AL burden, respectively. Cumulative adversity was associated with 3% (95% CI [1.01, 1.04]) higher AL burden. Adjusting for sociodemographic and lifestyle covariates rendered the association of childhood poverty (IRR= 1.04, 95% CI [.98, 1.09]; p = .190) and childhood physical abuse (IRR= 1.07, 95% CI [.99, 1.15]; p = .081) with AL burden nonsignificant, while the association of having an ill spouse/partner/child on AL persisted (IRR= 1.06, 95% CI [1.01, 1.11]; p = .021)., Conclusions: This study provided limited support for the idea that psychosocial stress leads to higher AL, with just three out of 11 adversities associated with AL. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: In 2017, 785 million people globally lacked access to basic services of drinking water and 2 billion people lived without basic sanitation services. Most of these people live in low- and lower-middle-income countries in South Asia, Southeast Asia and sub-Saharan Africa. To monitor the progress towards universal access to water and sanitation, this study aimed to predict the coverage of access to basic drinking water supply and sanitation (WSS) services as well as the reduction in the practice of open defecation by 2030, under two assumptions: following the current trends and accelerated poverty reduction., Methods and Findings: Households reporting access to basic WSS services and those practising open defecation were extracted from 210 nationally representative Demographic Health Surveys and Multiple Cluster Indicator Surveys (1994-2016) from 51 countries. A Bayesian hierarchical mixed effect linear regression model was developed to predict the indicators in 2030 at national, urban-rural and wealth-specific levels. A Bayesian regression model with accelerated reduction in poverty by 2030 was applied to assess the impact of poverty reduction on these indicators. Out of 51 countries, only nine (Bangladesh, Bhutan, Ghana, India, Nepal, Pakistan, The Philippines, Togo and Vietnam) were predicted to reach over 90% coverage in access to basic services of drinking water by 2030. However, none of the countries were projected to achieve equivalent coverage for access to basic sanitation services. By 2030, 21 countries were projected to achieve the target of less than 10% households practising open defecation. Urban-rural and wealth-derived disparities in access to basic WSS services, especially sanitation, were more pronounced in sub-Saharan Africa than South Asia and Southeast Asia. Access to basic sanitation services was projected to benefit more from poverty reduction than access to basic drinking water services. Households residing in rural settings were predicted to receive greater benefit from poverty reduction than urban populations in access to both basic WSS services., Conclusion: Achieving poverty eradication targets may have a substantial positive impact on access to basic water supply and sanitation services. However, many low- and lower-middle-income countries will struggle to achieve the goal of universal access to basic services, especially in the sanitation sector., (© 2021 John Wiley & Sons Ltd.)

Background: Child poverty rates are rising in Norway with potential negative consequences for children. Services for families with low income are often fragmented and poorly integrated, and few coordinated initiatives have been implemented and evaluated in Norway., Aims: The aim of the current study is to evaluate how integrated and coordinated services provided over a prolonged period by a family coordinator are related to changes across a wide range of health, wellbeing and home environment indicators for the participants., Methods: The study uses a mixed methods approach utilising survey and register data, as well as information from interviews and shadowing, to document and evaluate outcomes associated with the intervention and the process of implementation. Data are gathered at baseline and annually throughout the duration of the study. Participants are identified to facilitate longer-term follow-up using register data., Conclusions: This project will develop important knowledge about the implementation of coordinated services to families with a low income, and how this way of organizing services influences important outcomes for the family members in the short and long term.

Objectives: This study aimed to analyze any reported antibiotic use for children aged <5 years with fever, diarrhea or cough with fast or difficult breathing (outcome) from low-income and middle-income countries (LMICs) during 2005-2017 by user characteristics: rural/urban residence, maternal education, household wealth, and healthcare source visited., Methods: Based on 132 demographic and health surveys and multiple indicator cluster surveys from 73 LMICs, the outcome by user characteristics for all country-years was estimated using a hierarchical Bayesian linear regression model., Results: Across LMICs during 2005-2017, the greatest relative increases in the outcome occurred in rural areas, poorest quintiles and least educated populations, particularly in low-income countries and South-East Asia. In low-income countries, rural areas had a 72% relative increase from 17.8% (Uncertainty Interval (UI): 5.2%-44.9%) in 2005 to 30.6% (11.7%-62.1%) in 2017, compared to a 29% relative increase in urban areas from 27.1% (8.7%-58.2%) in 2005 to 34.9% (13.3%-67.3%) in 2017. Despite these increases, the outcome was consistently highest in urban areas, wealthiest quintiles, and populations with the highest maternal education., Conclusion: These estimates suggest that the increasing reported antibiotic use for sick children aged <5 years in LMICs during 2005-2017 was driven by gains among groups often underserved by formal health services., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Competing interests: None declared.

Importance: The root causes of violent crime in Black urban neighborhoods are structural, including residential racial segregation and concentrated poverty. Previous work suggests that simple and scalable place-based environmental interventions can overcome the legacies of neighborhood disinvestment and have implications for health broadly and crime specifically., Objective: To assess whether structural repairs to the homes of low-income owners are associated with a reduction in nearby crime., Design, Setting, and Participants: This cross-sectional study using difference-in-differences analysis included data from the City of Philadelphia Basic Systems Repair Program (BSRP) from January 1, 2006, through April 30, 2013. The unit of analysis was block faces (single street segments between 2 consecutive intersecting streets) with or without homes that received the BSRP intervention. The blocks of homes that received BSRP services were compared with the blocks of eligible homes that were still on the waiting list. Data were analyzed from December 1, 2019, to February 28, 2021., Exposures: The BSRP intervention includes a grant of up to $20 000 provided to low-income owners for structural repairs to electrical, plumbing, heating, and roofing damage. Eligible homeowners must meet income guidelines, which are set by the US Department of Housing and Urban Development and vary yearly., Main Outcomes and Measures: The main outcome was police-reported crime across 7 major categories of violent and nonviolent crimes (homicide, assault, burglary, theft, robbery, disorderly conduct, and public drunkenness)., Results: A total of 13 632 houses on 6732 block faces received the BSRP intervention. Owners of these homes had a mean (range) age of 56.5 (18-98) years, were predominantly Black (10 952 [78.6%]) or Latino (1658 [11.9%]) individuals, and had a mean monthly income of $993. These census tracts compared with those without BSRP intervention had a substantially larger Black population (49.5% vs 12.2%; |D| = 0.406) and higher unemployment rate (17.3% vs 9.3%; |D| = 0.357). The main regression analysis demonstrated that the addition to a block face of a property that received a BSRP intervention was associated with a 21.9% decrease in the expected count of total crime (incidence rate ratio [IRR], 0.78; 95% CI, 0.76-0.80; P < .001), 19.0% decrease in assault (IRR, 0.81; 95% CI, 0.79-0.84; P < .001), 22.6% decrease in robbery (IRR, 0.77; 95% CI, 0.75-0.80; P < .001), and 21.9% decrease in homicide (IRR, 0.78; 95% CI, 0.71-0.86; P < .001). When restricting the analysis to blocks with properties that had ever received a BSRP intervention, a total crime reduction of 25.4% was observed for each additional property (IRR, 0.75; 95% CI, 0.73-0.77; P < .001). A significant dose-dependent decrease in total crime was found such that the magnitude of association increased with higher numbers of homes participating in the BSRP on a block., Conclusions and Relevance: This study found that the BSRP intervention was associated with a modest but significant reduction in crime. These findings suggest that intentional and targeted financial investment in structural, scalable, and sustainable place-based interventions in neighborhoods that are still experiencing the lasting consequences of structural racism and segregation is a vital step toward achieving health equity.

Importance: The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown., Objective: To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income., Design, Setting, and Participants: This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not., Exposures: Implementation of the ACA., Main Outcomes and Measures: The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed., Results: The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states., Conclusions and Relevance: Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.

Background/purpose: Psychological distress can influence cancer mortality through socioeconomic disadvantage, health-risk behaviors, or reduced access to care. These disadvantages can result in higher risks of cancer occurrence, a delayed cancer diagnosis, hamper adherence to treatment, and provoke inflammatory responses leading to cancer. Previous studies have linked psychological distress to cancer mortality. However, studies are lacking for the U.S. population., Methods: This study examines the Kessler six-item psychological distress scale as a risk factor for U.S. cancer mortality using the pooled 1997-2014 data from the National Health Interview Survey (NHIS) linked to National Death Index (NDI) (N = 513,012). Cox proportional hazards regression was used to model survival time as a function of psychological distress and sociodemographic and behavioral covariates., Results: In Cox models with 18 years of mortality follow-up, the cancer mortality risk was 80% higher (hazard ratio [HR] = 1.80; 95% CI = 1.64, 1.97) controlling for age; 61% higher (HR = 1.61; 95% CI = 1.46, 1.76) in the SES-adjusted model, and 33% higher (HR = 1.33; 95% CI = 1.21, 1.46) in the fully-adjusted model among adults with serious psychological distress (SPD), compared with adults without psychological distress. Males, non-Hispanic Whites, and adults with incomes at or above 400% of the federal poverty level had greater cancer mortality risk associated with SPD. Using an 8 years of mortality follow-up, those with SPD had 108% increased adjusted risks of mortality from breast cancer., Conclusion: Our study findings underscore the significance of addressing psychological well-being in the population as a strategy for reducing cancer mortality., (© Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We examined the associations of dietary cholesterol and egg intakes with cardiometabolic and all-cause mortality among Chinese and low-income Black and White Americans. Included were 47,789 Blacks, 20,360 Whites, and 134,280 Chinese aged 40-79 years at enrollment. Multivariable Cox models with restricted cubic splines were applied to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality outcomes using intakes of 150 mg cholesterol/day and 1 egg/week as the references. Cholesterol intake showed a nonlinear association with increased all-cause mortality and a linear association with increased cardiometabolic mortality among Black Americans: HRs (95% CIs) associated with 300 and 600 mg/day vs. 150 mg/day were 1.07 (1.03-1.11) and 1.13 (1.05-1.21) for all-cause mortality ( P -linearity = 0.04, P -nonlinearity = 0.002, and P -overall < 0.001) and 1.10 (1.03-1.16) and 1.21 (1.08-1.36) for cardiometabolic mortality ( P -linearity = 0.007, P -nonlinearity = 0.07, and P -overall = 0.005). Null associations with all-cause or cardiometabolic mortality were noted for White Americans ( P -linearity ≥ 0.13, P -nonlinearity ≥ 0.06, and P -overall ≥ 0.05 for both). Nonlinear inverse associations were observed among Chinese: HR (95% CI) for 300 vs. 150 mg/day was 0.94 (0.92-0.97) for all-cause mortality and 0.91 (0.87-0.95) for cardiometabolic mortality, but the inverse associations disappeared with cholesterol intake > 500 mg/day ( P -linearity ≥ 0.12; P -nonlinearity ≤ 0.001; P -overall < 0.001 for both). Similarly, we observed a positive association of egg intake with all-cause mortality in Black Americans, but a null association in White Americans and a nonlinear inverse association in Chinese. In conclusion, the associations of cholesterol and egg intakes with cardiometabolic and all-cause mortality may differ across ethnicities who have different dietary patterns and cardiometabolic risk profiles. However, residual confounding remains possible.

The role of socio-economic status (SES) on the misreporting of food and energy intakes is not well understood with disagreement in the literature. The aim of this study was to examine the associations between low energy reporting, dietary quality and SES in a representative sample of adults. Dietary data were collected using 2 d of 24-h recalls for 6114 adults aged 19 years and over, participating in the Australian National Nutrition and Physical Activity Survey 2011-2012. Low energy reporters (LER) and plausible reporters (PR) were identified. Discretionary food intake was used as a proxy indicator of diet quality. SES was determined using area-level SES and educational attainment. Regression analysis was applied to examine the effects of LER and SES on diet quality, adjusting for potential confounders. LER was more common in populations of lower SES than higher SES (area-level OR 1·46 (95 % CI 1·06, 2·00); education OR 1·64 (95 % CI 1·28, 2·09). LER and SES were independently associated with diet quality, with LER reporting lower percentage energy from discretionary foods compared with PR (27·4 v. 34·2, P < 0·001), and those of lower area-level SES and education reporting lower diet quality compared with those of higher SES (33·7 v. 31·2, P < 0·001; and 33·5 v. 29·6, P < 0·001, respectively). No interaction effect was found between LER and SES, indicating percentage energy in discretionary foods was not differentially misreported across the SES areas (0·3078) or education (P = 0·7078). In conclusion, LER and higher SES were associated with better diet quality.

Background: On January 21, 2020, the World Health Organization reported the first case of severe acute respiratory syndrome coronavirus 2, which rapidly evolved to the COVID-19 pandemic. Since then, the virus has also rapidly spread among Latin American, Caribbean, and African countries., Objective: The first aim of this study is to identify new emerging COVID-19 clusters over time and space (from January 21 to mid-May 2020) in Latin American, Caribbean, and African regions, using a prospective space-time scan measurement approach. The second aim is to assess the impact of real-time population mobility patterns between January 21 and May 18, 2020, under the implemented government interventions, measurements, and policy restrictions on COVID-19 spread among those regions and worldwide., Methods: We created a global COVID-19 database, of 218 countries and territories, merging the World Health Organization daily case reports with other measures such as population density and country income levels for January 21 to May 18, 2020. A score of government policy interventions was created for low, intermediate, high, and very high interventions. The population's mobility patterns at the country level were obtained from Google community mobility reports. The prospective space-time scan statistic method was applied in five time periods between January and May 2020, and a regression mixed model analysis was used., Results: We found that COVID-19 emerging clusters within these five periods of time increased from 7 emerging clusters to 28 by mid-May 2020. We also detected various increasing and decreasing relative risk estimates of COVID-19 spread among Latin American, Caribbean, and African countries within the period of analysis. Globally, population mobility to parks and similar leisure areas during at least a minimum of implemented intermediate-level control policies (when compared to low-level control policies) was related to accelerated COVID-19 spread. Results were almost consistent when regional stratified analysis was applied. In addition, worldwide population mobility due to working during high implemented control policies and very high implemented control policies, when compared to low-level control policies, was related to positive COVID-19 spread., Conclusions: The prospective space-time scan is an approach that low-income and middle-income countries could use to detect emerging clusters in a timely manner and implement specific control policies and interventions to slow down COVID-19 transmission. In addition, real-time population mobility obtained from crowdsourced digital data could be useful for current and future targeted public health and mitigation policies at a global and regional level., (©Stefanos Tyrovolas, Iago Giné-Vázquez, Daniel Fernández, Marianthi Morena, Ai Koyanagi, Mark Janko, Josep Maria Haro, Yang Lin, Paul Lee, William Pan, Demosthenes Panagiotakos, Alex Molassiotis. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 14.06.2021.)

Objective and importance of study: Considerable evidence suggests that adverse social determinants of health (SDH), such as poor education, unemployment, food and housing insecurity, interpersonal violence, inadequate social support and poverty, are key determinants of health and wellbeing. This prospective cohort study piloted a screening tool to collect individual SDH data in a South Australian hospital inpatient population. We explored participants' attitudes to SDH screening in brief follow-up interviews., Methods: This mixed-methods study used an SDH screening tool to collect individual-level SDH data from inpatients living in a highly disadvantaged socio-economic area. Participants had a primary diagnosis of chronic obstructive pulmonary disease (COPD), heart failure (HF) or diabetes mellitus. Follow-up interviews were completed post discharge via telephone. Descriptive statistics were employed to examine the prevalence and type of adverse SDH reported by the sample. Thematic analysis was applied to explore participants' attitudes to the screening., Results: The sample population (N = 37) reported a substantial burden of a range of adverse SDH (mean 4.7 adverse SDH experienced per participant, standard deviation 2.8). Participants involved in follow-up interviews (n = 8) believed screening might enhance communication between healthcare providers and patients and assist in identifying underlying social problems., Conclusion: A screening tool for SDH was successfully used to collect individual-level data in a hospital setting. An array of adverse SDH was common in the sample population. Participants believed screening for SDH may potentially benefit doctors and patients. A larger study is required to more robustly characterise the adverse SDH affecting individuals in this population and to explore how the healthcare system might effectively intervene., Competing Interests: MB has received research grants (paid to his institution) from Gilead Sciences and honoraria from Gilead Sciences and ViiV Healthcare for participation in HIV advisory boards and the preparation and delivery of educational presentations.

Objective: To identify relationships between idiopathic intracranial hypertension (IIH) and socioeconomic determinants of health, such as low-income status and proximity to healthy food., Methods: This retrospective case-control study of adult female neuro-ophthalmology patients from one institution identified 223 women with and 4,783 women without IIH. Street addresses were geocoded and merged with US census data to obtain census tract-level information on income and food access. Choropleth maps visualized IIH clusters within certain neighborhoods. Logistic regression compared the proportion of patients with IIH from racial and ethnic minority backgrounds, low-income census tracts, and food deserts and swamps to controls without IIH., Results: In our cohort, when adjusted for age, women with IIH were more likely to be Black (odds ratio [OR] 3.96, 95% confidence interval [CI] 2.98-5.25), Hispanic (OR 2.23, 95% CI 1.14-4.36), and live in low-income tracts (OR 2.24, 95% CI 1.71-2.95) or food swamps (OR 1.54, 95% CI 1.15-2.07). Patients with IIH were less likely to live in food deserts than controls (OR 0.61, 95% CI 0.45-0.83). The association between Black race and IIH remained significant even after adjusting for other variables., Conclusion: IIH is more common among Black and Hispanic women than expected even when accounting for the demographics of a metropolitan city. Some of this relationship is driven by the association of obesity and IIH incidence with low income and proximity to unhealthy foods., (© 2021 American Academy of Neurology.)

Importance: COVID-19 lockdowns may affect economic and health outcomes, but evidence from low- and middle-income countries remains limited., Objective: To assess the economic security, food security, health, and sexual behavior of women at high risk of HIV infection in rural Kenya during the COVID-19 pandemic., Design, Setting, and Participants: This survey study of women enrolled in a randomized trial in a rural county in Kenya combined results from phone interviews, conducted while social distancing measures were in effect between May 13 and June 29, 2020, with longitudinal, in-person surveys administered between September 1, 2019, and March 25, 2020. Enrolled participants were HIV-negative and had 2 or more sexual partners within the past month. Surveys collected information on economic conditions, food security, health status, and sexual behavior. Subgroup analyses compared outcomes by reliance on transactional sex for income and by educational attainment. Data were analyzed between May 2020 and April 2021., Main Outcomes and Measures: Self-reported income, employment hours, numbers of sexual partners and transactional sex partners, food security, and COVID-19 prevention behaviors., Results: A total of 1725 women participated, with a mean (SD) age of 29.3 (6.8) years and 1170 (68.0%) reporting sex work as an income source before the COVID-19 pandemic. During the pandemic, participants reported experiencing a 52% decline in mean (SD) weekly income, from $11.25 (13.46) to $5.38 (12.51) (difference, -$5.86; 95% CI, -$6.91 to -$4.82; P < .001). In all, 1385 participants (80.3%) reported difficulty obtaining food in the past month, and 1500 (87.0%) worried about having enough to eat at least once. Reported numbers of sexual partners declined from a mean (SD) total of 1.8 (1.2) partners before COVID-19 to 1.1 (1.0) during (difference, -0.75 partners; 95% CI, -0.84 to -0.67 partners; P < .001), and transactional sex partners declined from 1.0 (1.1) to 0.5 (0.8) (difference, -0.57 partners; 95% CI, -0.64 to -0.50 partners; P < .001). In subgroup analyses, women reliant on transactional sex for income were 18.3% (95% CI, 11.4% to 25.2%) more likely to report being sometimes or often worried that their household would have enough food than women not reliant on transactional sex (P < .001), and their reported decline in employment was 4.6 hours (95% CI, -7.9 to -1.2 hours) greater than women not reliant on transactional sex (P = .008)., Conclusions and Relevance: In this survey study, COVID-19 was associated with large reductions in economic security among women at high risk of HIV infection in Kenya. However, shifts in sexual behavior may have temporarily decreased their risk of HIV infection.

Aims/introduction: Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data., Materials and Methods: We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome., Results: We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis., Conclusions: Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty., (© 2020 The Authors. Journal of Diabetes Investigation published by Asian Association for the Study of Diabetes (AASD) and John Wiley & Sons Australia, Ltd.)

Antimicrobial resistance (AMR) is a major threat to human health globally. Surveillance is a key activity to determine AMR burden, impacts, and trends and to monitor effects of interventions. Surveillance systems require efficient capture and onward sharing of high-quality laboratory data. Substantial investment is being made to improve laboratory capacity, particularly in low-income and middle-income countries (LMICs) with high disease burdens. However, building capacity for effective laboratory data management remains an under-resourced area, which, unless addressed, will limit progress towards comprehensive AMR surveillance in LMICs. The lack of a fit-for-purpose and open-source laboratory information management system software is of particular concern. In this Personal View, we summarise the technical requirements for microbiology laboratory data management, provide a snapshot of laboratory data management in LMIC laboratories, and describe the key steps required to improve the situation. Without action to improve information technology infrastructure and data management systems in microbiology laboratories, the ongoing efforts to develop capacity for AMR surveillance in LMICs might not realise their full potential., Competing Interests: Declaration of interests PT and NAF are members of the steering committee for the Wellcome laboratory information management system (LIMS) project. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)