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Objective: To quantify students' risk tolerance for in-person classes and willingness-to-pay for online-only instruction during the COVID-19 pandemic. Participants: 46 Columbia University public health graduate students. Methods: We developed a survey tool with a "standard gamble" exercise administered online by an interactive chat bot with full anonymity by students. Students were asked to trade between the risk of infection with COVID-19 and: (1) attending classes in-person, and (2) attending community parties. We also assessed willingness-to-pay for online-only tuition. Results: Students accepted a 23% (standard error [SE]: 4%) risk of infection to attend classes in-person and 15% of them expressed willingness to attend community parties even if the COVID-19 prevalence were high. Students were willing-to-pay only 48% (SE: 3%) of the regular, in-person tuition fees for online instruction. Conclusions: Public health students with a strong knowledge of COVID-19 transmission were willing to accept a significant risk of infection for in-person instruction. Trial registration: NA.

Abstract Background Social epidemiology seeks in part to understand how social factors--ideas, beliefs, attitudes, actions, and social connections--influence health. However, national health datasets have not kept up with the evolving needs of this cutting-edge area in public health. Sociological datasets that do contain such information, in turn, provide limited health information. Findings Our team has prospectively linked three decades of General Social Survey data to mortality information through 2008 via the National Death Index. In this paper, we describe the sample, the core elements of the dataset, and analytical considerations. Conclusions The General Social Survey-National Death Index (GSS-NDI), to be released publicly in October 2011, will help shape the future of social epidemiology and other frontier areas of public health research.

Abstract Background It is commonly believed that the pathophysiology of obesity arises from adiposity. In this paper, I forward a complementary explanation; this pathophysiology arises not from adiposity alone, but also from the psychological stress induced by the social stigma associated with being obese. Methods In this study, I pursue novel lines of evidence to explore the possibility that obesity-associated stigma produces obesity-associated medical conditions. I also entertain alternative hypotheses that might explain the observed relationships. Results I forward four lines of evidence supporting the hypothesis that psychological stress plays a role in the adiposity-health association. First, body mass index (BMI) is a strong predictor of serological biomarkers of stress. Second, obesity and stress are linked to the same diseases. Third, body norms appear to be strong determinants of morbidity and mortality among obese persons; obese whites and women – the two groups most affected by weight-related stigma in surveys – disproportionately suffer from excess mortality. Finally, statistical models suggest that the desire to lose weight is an important driver of weight-related morbidity when BMI is held constant. Conclusion Obese persons experience a high degree of stress, and this stress plausibly explains a portion of the BMI-health association. Thus, the obesity epidemic may, in part, be driven by social constructs surrounding body image norms.

Abstract Background Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients. Methods Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics. Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios. Results Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone. Conclusion Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.

Abstract Background We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City. Methods We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin. Results After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease (RR = 1.02, 95% confidence interval 1.02, 1.03), stroke (RR = 1.00, 95% confidence interval, 0.99, 1.01), and diabetes mellitus (RR = 0.96 95% confidence interval 0.94, 0.97) as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70 (95% confidence interval 0.67, 0.72) and the risk of hospitalization for diabetes is 0.39 (95% confidence interval 0.37, 0.42) relative to native-born persons. Conclusions South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations.

This study assesses whether anti-immigrant prejudice at the community level is prospectively associated with mortality. We used 10 waves of data from the General Social Survey (GSS) that were linked to mortality data via the National Death Index (NDI) for the period between 1993 and 2014 (n = 13,242). The 2014 GSS-NDI dataset is a nationally representative sample reporting social characteristics and attitudes in the United States that was prospectively linked to mortality data. Community-level prejudice was measured with 5 questions regarding anti-immigrant sentiments across 123 communities, defined using primary sampling units. Cox proportional hazards models tested the association between anti-immigrant prejudice and mortality hazard, controlling for covariates at the individual and community levels. Findings showed that among "other race" respondents, those born in the US had higher risk of mortality in communities with greater anti-immigrant prejudice, whereas foreign-born "other race" respondents had lower risk of mortality in communities with greater anti-immigrant prejudice. Sensitivity analyses indicated that the "other race" category was comprised largely of Asians and Hispanics, and that these results were similar for both groups. In contrast, anti-immigrant prejudice was not associated with mortality for foreign-born immigrants who self-report as white or black. We provide various hypotheses for why US-born immigrant groups seem to suffer higher mortality risk, while foreign-born immigrant groups do not, when they live in communities with high levels of prejudice.

There are 25 million displaced children worldwide, and those receiving schooling are often educated in overcrowded classrooms. Montessori is a child-centred educational method that provides an alternative model to traditional educational approaches. In this model, students are able to direct their own learning and develop at their own pace, working with materials rather than in supervised groups or with direct teacher instruction. Because most children are working alone, teachers have more time to work one-on-one with children even when student-teacher ratios are quite large. This gives teachers increased opportunity to tailor their teaching to the specific needs and strengths of each student. We conducted an evaluation of Montessori classroom conversion for displaced students on the Thai-Myanmar border. We administered the Ages and Stages Questionnaire (ASQ) to 66 children before and after classroom conversion and across treatment and control classroom conditions. We then conducted difference in difference testing. All domains showed meaningful improvements in ASQ scores, with the Montessori students gaining 18 points relative to the traditional students (p = 0.33). However, only the personal-social domain of the ASQ was statistically significant (8.8 point gain for the Montessori students relative to the control, p < 0.05) in our underpowered sample.

Objectives Historically, departures at New York City’s LaGuardia airport flew over a large sports complex within a park. During the US Open tennis games, flights were diverted to fly over a heavily populated foreign-born neighbourhood for roughly 2 weeks out of the year so that the tennis match was not disturbed (the ‘TNNIS’ departure). In 2012, the use of the TNNIS departure became year-round to better optimise flight patterns around the metropolitan area.Methods We exploited exogenously induced spatial and temporal variation in flight patterns to examine difference-in-difference effects of this new exposure to aircraft noise on the health of individual residents in the community relative to individuals residing within a demographically similar community that was not impacted. We used individual-level Medicaid records, focusing on conditions associated with noise: sleep disturbance, psychological stress, mental illness, substance use, and cardiovascular disease.Results We found that increased exposure to aeroplane noise was associated with a significant increase in insomnia across all age groups, but particularly in children ages 5–17 (OR=1.64, 95% CI=1.12 to 2.39). Cardiovascular disease increased significantly both among 18–44-year-old (OR=1.45, 95% CI=1.41 to 1.49) and 45–64-year-old Medicaid recipients (OR=1.15, 95% CI=1.07 to 1.25). Substance use and mental health-related emergency department visits also increased. For ages 5–17,rate ratio (RR) was 4.11 (95% CI=3.28 to 5.16); for ages 18–44, RR was 2.46 (95% CI=2.20 to 2.76); and for ages 45–64, RR was 1.48 (95% CI=1.31 to 1.67).Conclusion We find that increased exposure to aeroplane noise was associated with an increase in diagnosis of cardiovascular disease, substance use/mental health emergencies and insomnia among local residents.

Background Since the 2010 election, the number of laws in the U.S. that create barriers to voting has increased dramatically. These laws may have spillover effects on population health by creating a disconnect between voter preferences and political representation, thereby limiting protective public health policies and funding. We examine whether voting restrictions are associated with county-level COVID-19 case and mortality rates. Methods To obtain information on restricted access to voting, we used the Cost of Voting Index (COVI), a state-level measure of barriers to voting during a U.S. election from 1996 to 2016. COVID-19 case and mortality rates were obtained from the New York Times’ GitHub database (a compilation from multiple academic sources). Multilevel modeling was used to determine whether restrictive voting laws were associated with county-level COVID-19 case and mortality rates after controlling for county-level characteristics from the County Health Rankings. We tested whether associations were heterogeneous across racial and socioeconomic groups. Results A significant association was observed between increasing voting restrictions and COVID-19 case (ß = 580.5, 95% CI = 3.9, 1157.2) and mortality rates (ß = 16.5, 95% CI = 0.33,32.6) when confounders were included. Conclusions Restrictive voting laws were associated with higher COVID-19 case and mortality rates.

BackgroundMost universities that re-open in the United States (US) for in-person instruction have implemented the Centers for Disease Prevention and Control (CDC) guidelines. The value of additional interventions to prevent the transmission of SARS-CoV-2 is unclear. We calculated the cost-effectiveness and cases averted of each intervention in combination with implementing the CDC guidelines.MethodsWe built a decision-analytic model to examine the cost-effectiveness of interventions to re-open universities. The interventions included implementing the CDC guidelines alone and in combination with 1) a symptom-checking mobile application, 2) university-provided standardized, high filtration masks, 3) thermal cameras for temperature screening, 4) one-time entry ('gateway') polymerase chain reaction (PCR) testing, and 5) weekly PCR testing. We also modeled a package of interventions ('package intervention') that combines the CDC guidelines with using the symptom-checking mobile application, standardized masks, gateway PCR testing, and weekly PCR testing. The direct and indirect costs were calculated in 2020 US dollars. We also provided an online interface that allows the user to change model parameters.ResultsAll interventions averted cases of COVID-19. When the prevalence of actively infectious cases reached 0.1%, providing standardized, high filtration masks saved money and improved health relative to implementing the CDC guidelines alone and in combination with using the symptom-checking mobile application, thermal cameras, and gateway testing. Compared with standardized masks, weekly PCR testing cost $9.27 million (95% Credible Interval [CrI]: cost-saving-$77.36 million)/QALY gained. Compared with weekly PCR testing, the 'package' intervention cost $137,877 (95% CrI: $3,108-$19.11 million)/QALY gained. At both a prevalence of 1% and 2%, the 'package' intervention saved money and improved health compared to all the other interventions.ConclusionsAll interventions were effective at averting infection from COVID-19. However, when the prevalence of actively infectious cases in the community was low, only standardized, high filtration masks clearly provided value.

Objective To estimate the impact of state-level supplements of the Earned Income Tax Credit (EITC) on mortality in the USA. The EITC supplements the wages of lower-income workers by providing larger returns when taxes are filed.Setting Nationwide sample spanning 25 cohorts of people across every state in the USA.Participants 793 000 respondents within the National Longitudinal Mortality Survey (NLMS) between 1986 and 2011, a representative sample of the USA.Intervention State-level supplementation to the EITC programme. Some, but not all, states added EITC supplementation to varying degrees beginning in 1986 (Wisconsin) and most recently in 2015 (California). Participants who were eligible in states with supplementary programmes were compared with those who were not eligible for supplementation. Comparisons were made both before and after implementation of the supplementary programme (a difference-in-difference, intent-to-treat analysis). This quasi-experimental approach further controls for age, gender, marital status, race or ethnicity, educational attainment, income and employment status.Primary and secondary outcome measures The primary outcome measure was survival at 10 years. Secondary outcome measures included survival at 5 years and survival to the end of the intervention period.Results We find an association between state supplemental EITC and survival, with a HR of 0.973 (95% CI=0.951–0.996) for each US$100 of EITC increase (p

BackgroundProposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients.MethodsData from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics. Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios.ResultsMedicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone.ConclusionSupplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.

Privacy and confidentiality are often of great concern to respondents answering sensitive questions posed by interviewers. Using the 1993-2010 General Social Survey, we examined trends in the provision of social security numbers (SSNs) and correlates of those responses. Results indicate that the rate of SSN provision has declined over the past three decades, that is, from about 60% in 1993-1994 to 20% after 2004. Although younger, unmarried, and less-educated respondents are more likely to provide SSNs, an indicator of trust toward others is not a significant predictor of SSN provision. Further, those who refuse to report their income and who receive an incentive are less likely to provide their SSN. Our findings have implications for studies involving sensitive questions as well as privacy and confidentiality issues.

ObjectiveThe New Rural Cooperative Medical Scheme (NCMS) is a universal healthcare coverage plan now covering over 98% of rural residents in China, first implemented in 2003. Rising costs in the face of modest gains in health and financial protections have raised questions about the cost-effectiveness of the NCMS.MethodsUsing the most recent estimates of the NCMS's health and economic consequences from a comprehensive review of the literature, we conducted a cost-effectiveness analysis using a Markov model for a hypothetical cohort between ages 20 and 100. We then did one-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulations to explore whether the incremental cost-effectiveness ratio (ICER) falls below 37,059 international dollars [Int$], the willingness-to-pay (WTP) threshold of three times per capita GDP of China in 2013.FindingsThe ICER of the NCMS over the lifetime of an average 20-year-old rural resident in China was about Int$71,480 per quality-adjusted life year (QALY) gained (95% confidence interval: cost-saving, Int$845,659/QALY). There was less than a 33% chance that the system was cost-saving or met the WTP threshold. However, the NCMS did fall under the threshold when changes in the program costs, the risk of mortality and hypertension, and the likelihood of labor force participation were tested in one-way sensitivity analyses.ConclusionThe NCMS appears to be economically inefficient in its current form. Further cost-effectiveness analyses are warranted in designing insurance benefit packages to ensure that the NCMS fund goes toward health care that has a good value in improving survival and quality of life.

This paper calculates the public savings (financial benefits) from greater public investments in the education of African-American males. Over one-fifth of each age cohort of black males in US is not a high school graduate. We identify five interventions that would--based on credible research--increase the graduation rate; we also report the public cost of each intervention. We then calculate the lifetime public benefits in terms of increased tax revenues and lower spending on health and crime. In present values, for a black male aged 20, these public benefits amount to $256,700 per new graduate and the median intervention would cost only $90,700. The benefit/cost ratio is 2.83. Simply equating the high school graduation rate of black males with that of white males would yield public savings of $3.98 billion for each age cohort. These results suggest that increased investments in education for black males at risk of dropping out of high school should be an economic priority.

Our study examines the association between perceived discrimination due to race and unmet medical needs among a nationally representative sample of children in the United States. We used data from the 2016-2017 National Survey of Children's Health, a population-based cross-sectional survey of randomly selected parents or guardians in the United States. We compared results from the coarsened exact matching (CEM) method and survey-weighted logistic regression to assess the robustness of the results. Using self-reported measures from caregivers, we find that ∼2.7% of US children have experienced racial discrimination with prevalence varying significantly by race. While <1% of non-Hispanic whites have experienced some measure of racism, this increases to 8.8% among non-Hispanic blacks. Perceived discrimination was associated with significantly greater odds of unmet medical needs in the adjusted, survey-weighted multivariate-adjusted model (adjusted odds ratio [OR] = 2.4 and 95% confidence interval [CI] = 1.2, 4.9) as well as in the CEM-model estimate (OR = 2.8 and 95% CI = 1.8, 4.0). Children who have experienced perceived discrimination had higher odds of unmet medical needs. Awareness of discrimination among children may help inform future intervention development that addresses unmet medical needs during childhood. [ABSTRACT FROM AUTHOR]