Effect of economic recession on psychosocial working conditions by workers' nationality

Background: Several publications have documented the effects of economic recessions on health. However, little is known about how economic recessions influence working conditions, especially among vulnerable workers.

Objective: To explore the effects of 2008 economic crisis on the prevalence of adverse psychosocial working conditions among Spanish and foreign national workers.

Methods: Data come from the 2007 and 2011 Spanish Working Conditions Surveys. Survey year, sociodemographic, and occupational information were independent variables and psychosocial factors exposures were dependent variables. Analyses were stratified by nationality (Spanish versus foreign). Prevalence and adjusted prevalence ratios (aPRs) of psychological job demands, job control, job social support, physical demands and perceived job insecurity were estimated using Poisson regression.

Results: The Spanish population had higher risk of psychological and physical job demand (aPR =?1.07, 95% CI?=?[1.04–1.10] and aPR?=?1.05, 95% CI?=?[1.01–1.09], respectively) in 2011 compared to 2007. Among both Spanish and foreign national workers, greater aPR were found for job loss in 2011 compared to 2007 (aPR?=?2.47, 95% CI?=?[2.34–2.60]; aPR?=?2.44, 95% CI?=?[2.15–2.77], respectively).

Conclusion: The 2008 economic crisis was associated with a significant increase in physical demands in Spanish workers and increased job insecurity for both Spanish and foreign workers.     

Risky Party and Nightclub Attendance during the COVID-19 Nightlife Shutdown in New York City

From March 2020 through May 2021, nightlife venues were shut down and large gatherings were deemed illegal in New York City (NYC) due to COVID-19. This study sought to determine the extent of risky party attendance during the COVID-19 shutdown among people who attend electronic dance music parties in NYC. During the first four months that venues were permitted to reopen (June through September 2021), time–space sampling was used to survey adults (n = 278) about their party attendance during the first year of the shutdown (March 2020–March 2021). We examined prevalence and correlates of attendance and mask-wearing at such parties. A total of 43.9% attended private parties with more than 10 people, 27.3% attended nightclubs, and 20.5% attended other parties such as raves. Among those who attended any, 32.3% never wore a mask and 19.3% reported attending parties in which no one wore a mask. Past-year ecstasy use was associated with increased risk for attending private (aPR = 1.51, 95% CI: 1.00–2.28) or other parties (aPR = 2.75, 95% CI: 1.48–5.13), and use of 2C series drugs was associated with increased risk for attending nightclubs (aPR = 2.67, 95% CI: 1.24–5.77) or other parties (aPR = 2.50, 95% CI: 1.06–5.87). Attending >10 parties was associated with increased risk for never wearing a mask (aPR = 2.74, 95% CI: 1.11–6.75) and for no other attendees wearing masks (aPR = 4.22, 95% CI: 1.26–14.07). Illegal dance parties continued in NYC during the COVID-19 shutdown. Prevention and harm reduction efforts to mitigate risk of COVID-19 transmission during such shutdowns are sorely needed.     

The Association Between Race/Ethnicity and Major Birth Defects in the United States, 1999–2007

Objectives. We investigated the relationship between race/ethnicity and 27 major birth defects.Methods. We pooled data from 12 population-based birth defects surveillance systems in the United States that included 13.5 million live births (1 of 3 of US births) from 1999 to 2007. Using Poisson regression, we calculated prevalence estimates for each birth defect and 13 racial/ethnic groupings, along with crude and adjusted prevalence ratios (aPRs). Non-Hispanic Whites served as the referent group.Results. American Indians/Alaska Natives had a significantly higher and 50% or greater prevalence for 7 conditions (aPR = 3.97; 95% confidence interval [CI] = 2.89, 5.44 for anotia or microtia); aPRs of 1.5 to 2.1 for cleft lip, trisomy 18, and encephalocele, and lower, upper, and any limb deficiency). Cubans and Asians, especially Chinese and Asian Indians, had either significantly lower or similar prevalences of these defects compared with non-Hispanic Whites, with the exception of anotia or microtia among Chinese (aPR = 2.08; 95% CI = 1.30, 3.33) and Filipinos (aPR = 1.90; 95% CI = 1.10, 3.30) and tetralogy of Fallot among Vietnamese (aPR = 1.60; 95% CI = 1.11, 2.32).Conclusions. This is the largest population-based study to our knowledge to systematically examine the prevalence of a range of major birth defects across many racial/ethnic groups, including Asian and Hispanic subgroups. The relatively high prevalence of birth defects in American Indians/Alaska Natives warrants further attention.Birth defects are a leading cause of infant mortality, accounting for 1 in 5 infant deaths in the United States, and these defects contribute substantially to childhood and adult disability, as well as to health care costs.1–3 The examination of racial/ethnic variations in birth defects provides clues regarding their etiology from genetic, cultural, environmental, and other factors. The United States has a relatively large, diverse population, providing an opportunity to examine variations among racial/ethnic groups and specific subgroups.Several population-based studies have examined the racial/ethnic variation of selected birth defects in the United States.4–9 In addition, a number of publications from individual states have included racial/ethnic data for either specific birth defects or a range of conditions.10–31 These studies have generally focused on a limited number of racial/ethnic groups or birth defects.Two previous population-based analyses, conducted through the National Birth Defects Prevention Network (NBDPN), provided clues concerning racial/ethnic variation for a range of birth defects using a large US birth sample.6,32 However, these analyses did not adjust for important covariates and only examined differences among Blacks and Hispanics relative to Whites. For the present study, we used more recent pooled population-based prevalence data over a longer period of time and for a wider range of racial/ethnic groups to examine differences in the prevalence of birth defects. Our objective was to examine the racial/ethnic differences in the occurrence of 27 major birth defects in the United States.     

Characterization of Healthy Housing in Africa: Method,Profiles, and Determinants

Housing is a key social determinant of health with implications for both physical and mental health. The measurement of healthy housing and studies characterizing the same in sub-Saharan Africa (SSA) are uncommon. This study described a methodological approach employed in the assessment and characterization of healthy housing in SSA using the Demographic and Health Survey (DHS) data for 15 countries and explored healthy housing determinants using a multiple survey-weighted logistic regression analysis. For all countries, we demonstrated that the healthy housing index developed using factor analysis reasonably satisfies both reliability and validity tests and can therefore be used to describe the distribution of healthy housing across different groups and in understanding the linkage with individual health outcomes. We infer from the results that unhealthy housing remains quite high in most SSA countries. Having a male head of the household was associated with decreased odds of healthy housing in Burkina Faso (OR = 0.80, CI = 0.68–0.95), Cameroon (OR = 0.65, CI = 0.57, 0.76), Malawi (OR = 0.70, CI = 0.64–0.78), and Senegal (OR = 0.62, CI = 0.51–0.74). Further, increasing household size was associated with reducing odds of healthy housing in Kenya (OR = 0.53, CI = 0.44–0.65), Namibia (OR = 0.34, CI = 0.24–0.48), Nigeria (OR = 0.57, CI = 0.46–0.71), and Uganda (OR = 0.79, CI = 0.67–0.94). Across all countries, household wealth was a strong determinant of healthy housing, with middle and rich households having higher odds of residing in healthy homes compared to poor households. Odds ratios ranged from 3.63 (CI = 2.96–4.44) for households in the middle wealth group in the DRC to 2812.2 (CI = 1634.8–4837.7) in Namibia’s wealthiest households. For other factors, the analysis also showed variation across countries. Our findings provide timely insights for the implementation of housing policies across SSA countries, drawing attention to aspects of housing that would promote occupant health and wellbeing. Beyond the contribution to the measurement of healthy housing in SSA, our paper highlights key policy and program issues that need further interrogation in the search for pathways to addressing the healthy housing deficit across most SSA countries. This has become critical amid the COVID-19 pandemic, where access to healthy housing is pivotal in its control.     

Work in Multiple Jobs and the Risk of Injury in the US Working Population

Objectives. We compared the risk of injury for multiple job holders (MJHs) with that for single job holders (SJHs).Methods. We used information from the National Health Interview Survey for the years 1997 through 2011 to estimate the rate of multiple job holding in the United States and compared characteristics and rates of self-reported injury (work and nonwork) for SJHs versus MJHs.Results. Approximately 8.4% of those employed reported working more than 1 job in the week before the interview. The rate of work and nonwork injury episodes per 100 employed workers was higher for MJHs than for SJHs (4.2; 95% confidence interval [CI] = 3.5, 4.8; vs 3.3; 95% CI = 3.1, 3.5 work injuries and 9.9; 95% CI = 8.9, 10.9; vs 7.4; 95% CI = 7.1, 7.6 nonwork injuries per 100 workers, respectively). When calculated per 100 full-time equivalents (P < .05), the rate ratio remained higher for MJHs.Conclusions. Our findings suggest that working in multiple jobs is associated with an increased risk of an injury, both at work and not at work, and should be considered in injury surveillance.Over the past 5 decades there have been many changes in the nature of work in the United States, primarily driven by shifts in the economy, technological advances, and globalization.1,2 Nearly half of the civilian employed population in the United States currently have some college education,3 but a significant number of workers take on part-time work and change jobs several times, especially new graduates in the first few years of employment.4–6According to the Bureau of Labor Statistics (BLS) Current Population Survey (CPS), in 2011 approximately 5% of US workers reported working in more than 1 job in the same week.7 The BLS American Time Use Survey (ATUS), which has a smaller sample and diary format, reports higher rates of multiple job holding in the same week (11% in 2011).8 Paxson and Sicherman9 estimated that up to 20% of male US workers are employed in multiple jobs over the course of a year. Employment in multiple jobs can take on many different forms, seldom captured in surveys: seasonal work concurrent or alternating with a primary job, working an additional job on the weekends,10 working 2 consecutive shifts in separate jobs, possibly full or part time, etc. The discrepancy in the prevalence of multiple job holders (MJHs) from the different national data sources is likely attributable to variations in definitions, or survey or sampling methods.Economists cite 2 main incentives for working in more than 1 job11–13: (1) needing extra income, currently constituting approximately 64% of all MJHs12 and (2) advancing their skills or entrepreneurial opportunity. These different reasons for multiple job holding, however, are likely not mutually exclusive.14The effect of working multiple jobs on work and nonwork injury has only been minimally explored. One recent study in Wisconsin reported that youths aged 14 to 18 years who worked in multiple jobs had more injuries and more serious injuries than those who worked in only 1 job.15 This study, however, was limited to a specific population with a small sample size.None of the current injury surveillance systems in the United States addresses the dynamic fluctuations in type of work, work hours, and work processes during the week or year before an injury. For the past 30 years, occupational injury research and standard surveillance systems have almost exclusively described injury morbidity relative to exposures at the worker’s primary job or the job in which the worker was working when injured.We explored the effect of working multiple jobs on work and nonwork injury by using data from the National Health Interview Survey (NHIS). This strategically weighted sample is designed to produce national estimates representative of the US civilian, noninstitutionalized population on a broad range of health topics. Survey respondents are asked to report whether they worked in more than 1 job in the past week and whether they were injured in the past 3 months. With these data, we estimated the prevalence of MJHs and single job holders (SJHs) in the United States, described similarities and differences in demographic and work characteristics for the 2 groups, and tested our hypothesis that those who work in multiple jobs are at increased risk of both work and nonwork injury compared with those who work in only 1 job. We pooled survey data on multiple job holding and injuries across 15 years (1997–2011). We also compared the prevalence of multiple job holding in the NHIS with published statistics from other national surveys.     

Is the Association between Neighborhood Drug Prevalence and Marijuana use Independent of Peer Drug and Alcohol Norms? Results from a Household Survey of Urban Youth

To inform policy debates surrounding marijuana decriminalization and add to our understanding of social and structural influences on youth drug use, we sought to determine whether there was an independent association between neighborhood drug prevalence and individual-level marijuana use after controlling for peer drug and alcohol norms. We analyzed cross-sectional data from a household survey of 563 youth aged 15–24 in Baltimore, Maryland. The study population was 88 % African-American. Using gender-stratified, weighted, multilevel logistic regression, we tested whether neighborhood drug prevalence was associated with individual-level marijuana use after controlling for peer drug and alcohol norms. Bivariate analyses identified a significant association between high neighborhood drug prevalence and marijuana use among female youth (AOR = 1.76, 95 % CI = 1.26, 2.47); the association was in a similar direction but not significant among male youth (AOR = 1.26, 95 % CI = 0.85, 1.87). In multivariable regression controlling for peer drug and alcohol norms, high neighborhood drug prevalence remained significantly associated among female youth (AOR = 1.59, 95 % CI = 1.12, 2.27). Among male youth, the association was attenuated toward the null (AOR = 0.95, 95 % CI = 0.63, 1.45). In the multivariable model, peer drug and alcohol norms were significantly associated with individual-level marijuana use among female youth (AOR = 1.54, 95 % CI = 1.17, 2.04) and male youth (AOR = 2.59, 95 % CI = 1.65, 4.07). This work suggests that individual-level marijuana use among female youth is associated with neighborhood drug prevalence independent of peer norms. This finding may have important implications as the policy landscape around marijuana use changes.     

Job Strain and Health-Related Lifestyle: Findings From an Individual-Participant Meta-Analysis of 118?000 Working Adults

Objectives. We examined the associations of job strain, an indicator of work-related stress, with overall unhealthy and healthy lifestyles.Methods. We conducted a meta-analysis of individual-level data from 11 European studies (cross-sectional data: n = 118 701; longitudinal data: n = 43 971). We analyzed job strain as a set of binary (job strain vs no job strain) and categorical (high job strain, active job, passive job, and low job strain) variables. Factors used to define healthy and unhealthy lifestyles were body mass index, smoking, alcohol intake, and leisure-time physical activity.Results. Individuals with job strain were more likely than those with no job strain to have 4 unhealthy lifestyle factors (odds ratio [OR] = 1.25; 95% confidence interval [CI] = 1.12, 1.39) and less likely to have 4 healthy lifestyle factors (OR = 0.89; 95% CI = 0.80, 0.99). The odds of adopting a healthy lifestyle during study follow-up were lower among individuals with high job strain than among those with low job strain (OR = 0.88; 95% CI = 0.81, 0.96).Conclusions. Work-related stress is associated with unhealthy lifestyles and the absence of stress is associated with healthy lifestyles, but longitudinal analyses suggest no straightforward cause–effect relationship between work-related stress and lifestyle.Behavior-related modifiable health risk factors, such as smoking and physical inactivity, are major contributors to the noncommunicable disease burden and mortality worldwide.1 These factors tend to cluster at the population level, with some people having multiple health risk factors (an overall unhealthy lifestyle) and others having multiple health-promoting factors (an overall healthy lifestyle)2,3; the causes of this clustering are not well understood, however. Work-related psychosocial stress may be one (possibly modifiable) factor influencing or contributing to adoption or maintenance of a healthy or unhealthy lifestyle. For instance, some people who experience stress may not find time to exercise or eat a healthy diet, or they may attempt to alleviate stress by smoking or drinking excessive amounts of alcohol, whereas others may choose healthy behaviors (e.g., exercise) as a way of coping with stress.4Work and workplace-related issues are common sources of stress. A better understanding of the association between work-related stress and overall health-related lifestyle is important because there is evidence from studies of cardiovascular diseases and cancer that combinations of lifestyle risk factors may induce larger risks of adverse health outcomes than the sum of the separate effects of the same factors2,5–7; there is also evidence that the co-occurrence of multiple healthy lifestyle factors has a protective effect against many diseases, including stroke and cancer.8–10 Psychosocial stress at work has been shown to be associated with individual unhealthy lifestyle factors such as smoking,11–14 heavy alcohol consumption,15–17 physical inactivity,18–21 and obesity.22–26 However, the relationship between work-related stress and the co-occurrence of healthy and unhealthy lifestyle factors remains poorly understood.We investigated the associations of work-related psychosocial stress, operationalized as job strain, with overall healthy and unhealthy lifestyles, operationalized as the co-occurrence of unhealthy and healthy lifestyle factors. We hypothesized that the association between job strain and health-related lifestyles would be stronger than the association between job strain and each individual unhealthy lifestyle factor. To examine these issues, we conducted a meta-analysis of data from 11 prospective European cohort studies.     

Drawing the Curtain Back on Injured Commercial Bicyclists

Objectives. We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City’s (NYC’s) central business district.Methods. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses.Results. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723).Conclusions. Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.In the United States in 2012, 726 bicyclists were killed and 49 000 were injured in motor vehicle collisions1–3; these fatalities accounted for 2.2% of motor vehicle–related deaths, but represented a 6.5% increase from 2011.1,2 In New York City (NYC), there were 4207 bicycle collisions in 2012 that resulted in injury, including 20 fatalities.4An estimated 185 000 people bike in NYC daily; of these, 5000 are commercial bicyclists making deliveries.5 Although commercial bicyclists include only 2.7% of bicyclists in NYC, they account for 16% of daily bicycle trips, at an average of 22 trips per day per commercial bicyclist.5 There are an estimated 109 375 food delivery trips made daily across NYC, covering 100 000 miles.5 NYC businesses have been required to provide employee bicyclists with helmets and safety gear, including reflectors, since 2007 and identification cards and reflective vests since 2013.6–9 Following a 10-month safety education initiative for business owners, the NYC Department of Transportation (DOT) increased enforcement of existing commercial bicycling safety laws in April 2013 by deploying inspectors to businesses to issue violations for missing or improper safety equipment and nonadherence to mandatory safety courses.10–12Commercial bicyclists represent a unique population whose characteristics, behaviors, and injuries have not been previously documented. A comprehensive literature search yielded only 3 articles13–15 relevant to the subject matter, emphasizing the need for more data on this population. Furthermore, current New York State and City databases do not identify injured bicyclists as commercial or noncommercial.1,4 Previous work from our trauma center revealed that 43% of injured bicyclists involved in motor vehicle collisions were commercial.16,17 Although commercial bicyclists provide a convenient service in many urban centers, essential information regarding their safety practices, behaviors, and outcomes in the event of injury is lacking. Our hypothesis was that commercial bicyclists represent a distinct cohort of vulnerable roadway users with a high minority representation. The objective of this study was to describe the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating NYC’s central business district.     

Burn and Cut Injuries Related to Job Stress among Kitchen Workers in Japan

To clarify the correlation between kitchen work-related burns and cuts and job stress, a self-administered questionnaire survey was conducted involving 991 kitchen workers among 126 kitchen facilities. The demographics, condition of burns and cuts, job stress with the Brief Job Stress Questionnaire (BJSQ), health condition, and work-related and environmental factors were surveyed. Multiple logistic regression models and trend tests were used according to quartiles (Q1, Q2, Q3, and Q4) of each sub-scale BJSQ. After adjustment for potential confounding variables, burns/cuts were associated with a higher score category (Q4) of job demands (OR: 2.56, 95% CI: 1.10–6.02/OR: 2.72, 95% CI: 1.30–5.69), psychological stress (OR: 4.49, 95% CI: 2.05–9.81/OR: 3.52, 95% CI: 1.84–6.72), and physical stress (OR: 2.41, 95% CI: 1.20–4.98/OR 2.16, 95% CI: 1.16–4.01). The ORs of the burn/cut injures increased from Q1 to Q4 with job demands (p for trend = 0.045/0.003), psychological stress (p for trend<0.001/0.001), and physical stress (p for trend = 0.006/0.005), respectively. These findings suggest that kitchen work-related burns and cuts are more likely to be correlated with job stress, and the higher the job stress score, the higher the frequency of burns and cuts among kitchen workers.     

Physical Activity and Dietary Determinants of Weight Loss Success in the US General Population

Objectives. I studied lifestyle behaviors of long-term weight losers in a nationally representative sample.Methods. I categorized the dietary and physical activity data of 8012 adults from the 2009–2012 National Health and Nutrition Examination Surveys into (1) long-term weight losers (≥ 10% loss for ≥ 1 year), (2) recent weight losers (≥ 10% loss within past year), and (3) overweight or obese individuals who never lost 10% or more of their weight.Results. Long-term weight losers consumed fewer calories (2072; 95% confidence interval [CI] = 2011, 2134 kcal vs 2211; 95% CI = 2173, 2249 kcal; P < .001) and were more likely to report any vigorous leisure activity (24.5% vs 20.3%; P = .027) than did overweight or obese individuals. Among those engaging in vigorous leisure activity, long-term weight losers reported a greater quantity (188; 95% CI = 159, 223 min × wk^–1 vs 156; 95% CI = 142, 172 min × wk^–1; P = .047). Recent weight losers did not differ from overweight or obese individuals on absolute calorie intake but reported less fat (79; 95% CI = 75, 83 g vs 84; 95% CI = 82, 86 g; P = .016) and more activity.Conclusions. Balanced calorie restriction from all macronutrients and physical activity are important behaviors for successful long-term weight loss in the general population.Approximately 17% of children and adolescents and 35% of adults in the United States are obese.1 The societal costs of obesity are staggering, with direct and indirect costs rising in a curvilinear fashion with body mass index (BMI; defined as weight in kilograms divided by the square of height in meters).2 On an individual level, obesity is associated with numerous deleterious health outcomes, including type II diabetes, cancer, coronary artery disease, sleep apnea, and cognitive dysfunction.3As a result of these overwhelming societal and individual costs, much attention has been paid to evaluating the efficacy of various weight loss interventions. Randomized trials of diet and physical activity interventions demonstrate that substantial weight loss can be achieved by most individuals, especially during the initial 6 months of an intervention.4,5 Randomized trials of weight loss, however, are somewhat limited by the expense and difficulty of including extended follow-up periods. In addition, weight loss usually begins to regress toward baseline after a year or more,5,6 which suggests that some of the interventions used may not be optimal for long-term weight loss maintenance. Furthermore, the individuals included in these trials represent a small segment of the general population (e.g., educated non-Hispanic White women are often overrepresented),4–6 preventing inferences about the success or failure of these interventions on a larger scale.In light of these limitations of randomized trials, observational studies have attempted to characterize lifestyle behaviors of populations that have lost a substantial amount of weight.7–11 Although these investigations provide insight into some of the behaviors associated with successful weight loss, they have either used convenience sampling11 or failed to report extensive information on dietary nutrient intakes and physical activity patterns.7–10 Consequently, the findings from these investigations apply only to a select portion of the general population or lack detail on the specific dietary and physical activity patterns used by the most successful weight losers.The National Health and Nutrition Examination Survey (NHANES) uses a complex sampling design to achieve a representative sample of the noninstitutionalized US population. NHANES assesses the health status and lifestyle behaviors of Americans through interviews, examinations, and laboratory tests. Information on dietary intake is collected through standardized 24-hour recalls, and participants report physical activity participation and weight history. As a result, NHANES provides an opportunity to examine dietary nutrient intakes and physical activity patterns among Americans who have successfully lost weight as well as among those who have successfully maintained weight loss for a prolonged period.I compared the dietary and physical activity patterns of overweight or obese individuals with those who have maintained substantial weight loss for more than 1 year as well as those who have lost weight within the past year.     

Association of Insurance Status and Age With Cervical Cancer Stage at Diagnosis: National Cancer Database, 2000–2007

Objectives. We examined the relationship of age at diagnosis and insurance status with stage among cervical cancer patients aged 21 to 85 years.Methods. We selected data on women (n = 69 739) diagnosed with invasive cervical cancer between 2000 and 2007 from the National Cancer Database. We evaluated the association between late stage (stage III/IV) and both insurance and age, with adjustment for race/ethnicity and other sociodemographic and clinical factors. We used multivariable log binomial models to estimate risk ratios (RRs) and 95% confidence intervals (CIs).Results. The proportion of late-stage disease increased with age: from 16.53% (21–34 years) to 42.44% (≥ 70 years). The adjusted relative risk of advanced-stage disease among women aged 50 years and older was 2.2 to 2.5 times that of patients aged 21 to 34 years. Uninsured (RR = 1.44; 95% CI = 1.40, 1.49), Medicaid (RR = 1.37, 95% CI = 1.34, 1.41), younger Medicare (RR = 1.12, 95% CI = 1.06, 1.19), and older Medicare (RR = 1.20, 95% CI = 1.15, 1.26) patients had a higher risk of late-stage disease than did privately insured patients.Conclusions. Screening should be encouraged for women at high risk for advanced-stage disease.The American Cancer Society estimates that 12 710 women will be diagnosed with cervical cancer and 4290 women will die from the disease in 2011.1 Although incidence and mortality from cervical cancer have declined since the introduction of the Papanicolaou (Pap) test, approximately 35% of cervical cancer patients are diagnosed with regional disease and 11% with distant-stage disease.2,3 Prognosis is strongly related to stage: the 5-year relative survival rate is 91.2% for patients with localized disease, but only 57.8% for patients with regional disease and 17.0% for those with distant disease.3Socioeconomic status, race, marital status, and geographic location have been identified as factors related to late stage at diagnosis among cervical cancer patients.4–10 Previous studies also documented older age as a significant predictor of advanced stage, although the effects of insurance and age, which are 2 of the strongest predictors of cervical cancer screening, have not been studied together.11,12 Women without health insurance are less likely to receive cervical cancer and other recommended cancer screening tests, yet few studies have examined the association between insurance status and cervical cancer stage at diagnosis, and the existing studies were limited to elderly (aged ≥ 65 years) Medicare recipients or patients from single-state tumor registries.4,13 We examined the relationship of both age and insurance status with late-stage disease after adjustment for other known risk factors. Ours was the first study to our knowledge to examine this relationship in a large national sample of cancer patients.     

Health Effects of Unemployment Benefit Program Generosity

Objectives. We assessed the impact of unemployment benefit programs on the health of the unemployed.Methods. We linked US state law data on maximum allowable unemployment benefit levels between 1985 and 2008 to individual self-rated health for heads of households in the Panel Study of Income Dynamics and implemented state and year fixed-effect models.Results. Unemployment was associated with increased risk of reporting poor health among men in both linear probability (b = 0.0794; 95% confidence interval [CI] = 0.0623, 0.0965) and logistic models (odds ratio = 2.777; 95% CI = 2.294, 3.362), but this effect is lower when the generosity of state unemployment benefits is high (b for interaction between unemployment and benefits = −0.124; 95% CI = −0.197, −0.0523). A 63% increase in benefits completely offsets the impact of unemployment on self-reported health.Conclusions. Results suggest that unemployment benefits may significantly alleviate the adverse health effects of unemployment among men.An extensive body of research has linked job loss to poorer physical and mental health1 and higher risk of premature death.2 Recent literature has focused on establishing the causal nature of this association,2–8 but few studies have explored whether specific social programs modify the health effects of job loss. Understanding the impact of policies is useful for identifying intervention approaches to reduce the harms associated with unemployment, but they may also reveal some of the mechanisms explaining the association between job loss and health. Job loss is associated with a substantial loss in earnings.9 If earnings losses are the primary mechanism linking job loss to health, we would expect generous unemployment benefit programs to mitigate some of the negative consequences of job loss on health. On the other hand, unemployment benefits may be less effective if job loss influences health primarily through nonfinancial mechanisms, such as the loss of a time structure for the day, decreased self-esteem, chronic stress,10 or changes in health-related behavior.A few studies have investigated the association between unemployment benefit receipt and self-reported health measures.11–13 For example, Rodriguez11 analyzed self-reported health data from Britain, Germany, and the United States and found that unemployed workers in receipt of unemployment benefits do not have statistically higher likelihood of reporting poor health compared with the employed, while unemployed workers receiving no benefits are in worse health than these 2 groups. She concluded that benefit receipt moderates the association between unemployment and poor subjective health. Similarly, McLeod et al.14 found that unemployed US workers not receiving benefits are more likely to report poor health than employed workers, but the health of unemployed workers in receipt of benefits does not statistically differ from the health of employed workers. The association between receiving benefits and health was most pronounced among low-skilled unemployed workers, who appear to gain substantially from receipt of cash benefits.A key caveat in these studies is that they do not account for selection into benefit receipt, a bias that could lead to either over- or underestimation of effects. For example, if those who lose their jobs are healthier and more likely to be eligible for and receive unemployment benefits, the health benefits of unemployment benefits will be overestimated. During the recent recession, for example, non-Hispanic White race, higher educational level, and being married, characteristics associated with better health, also predicted receipt of benefits among long-term unemployed workers.15 On the other hand, job losers in poor health may anticipate longer-term spells of unemployment and therefore may be more likely to claim unemployment benefits than healthier individuals who expect to quickly find new employment. While 61% of workers in manufacturing and 66% of workers in construction were receiving benefits in the period 2008 to 2011, only 52% of professional and management workers and 49% of workers in the retail trade industry were receiving benefits in the same period.15 These findings suggest that selection is a serious source of potential bias in the relationship between unemployment benefit receipt and health, though the direction of bias is unclear.In the United States, the Federal–State Unemployment Insurance Program provides temporary wage replacement for eligible workers who become unemployed through no fault of their own. Although all states must follow general rules established at the federal level relating to coverage and eligibility, each state operates its own program. As a result, there is considerable variation in the generosity of unemployment benefit programs across states and over time. An approach to account for selection is to exploit these variations in the generosity of unemployment benefit programs to understand their effects on the health of workers. The assumption is that changes in unemployment benefit policy are uncorrelated with a worker’s health or other characteristics, as individuals have no control over the policy at the time they experience job loss. Variations in unemployment benefit generosity across states and over time, therefore, offer a unique natural experiment to estimate the impact of this policy on the health of unemployed workers.In a recent study, Cylus et al. exploited these variations to assess whether unemployment benefits moderate the relationship between aggregate unemployment rates and suicide,16 which are known to increase during recessions.17,18 Findings from this study suggest that more generous unemployment benefits are associated with a weaker effect of recessions on suicide. However, this study was based on aggregate data and did not estimate whether unemployment benefits reduced the negative impact of job loss among unemployed workers or whether benefits might in fact lead to improvements in mental health among both employed and unemployed workers, for example, by reducing the stress associated with the fear of job loss.19 Likewise, it is not clear whether results for suicide are applicable to self-rated health, a measure that combines elements of both physical and mental health, and a strong predictor of mortality.20In this study, we assessed the impact of unemployment benefit programs on the health of the unemployed. We hypothesized that income from unemployment benefits reduces psychological and physical morbidity among displaced workers such that individuals losing their job at a time of more generous unemployment benefit policies will suffer fewer health consequences than comparable individuals losing their jobs during years of lower benefit generosity. By focusing on unemployment benefit program generosity at the state level, we circumvent the bias generated by selection into benefits in the aforementioned studies.21,22 To identify this effect, we exploited variation in state unemployment benefit program generosity across US states and linked these to longitudinal individual-level data.     

Free Bus Travel and Physical Activity,Gait Speed,and Adiposity in the English Longitudinal Study of Ageing

Objectives. We investigated associations between having a bus pass, enabling free local bus travel across the United Kingdom for state pension–aged people, and physical activity, gait speed, and adiposity.Methods. We used data on 4650 bus pass–eligible people (aged ≥ 62 years) at wave 6 (2012–2013) of the English Longitudinal Study of Ageing in regression analyses.Results. Bus pass holders were more likely to be female (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.38, 2.02; P < .001), retired (OR = 2.65; 95% CI = 2.10, 3.35; P < .001), without access to a car (OR = 2.78; 95% CI = 1.83, 4.21; P < .001), to use public transportation (OR = 10.26; 95% CI = 8.33, 12.64; P < .001), and to be physically active (OR = 1.43; 95% CI = 1.12, 1.84; P = .004). Female pass holders had faster gait speed (b = 0.06 meters per second; 95% CI = 0.02, 0.09; P = .001), a body mass index 1 kilogram per meter squared lower (b = –1.20; 95% CI = –1.93, –0.46; P = .001), and waist circumference 3 centimeters smaller (b = –3.32; 95% CI = –5.02, –1.62; P < .001) than women without a pass.Conclusions. Free bus travel for older people helps make transportation universally accessible, including for those at risk for social isolation. Those with a bus pass are more physically active. Among women in particular, the bus pass is associated with healthier aging.Maintaining physical activity is key to good physical functioning in older age,1 aging healthily,2 and reducing obesity risk,3 but only 49% of men and 36% of women aged 65 years and older in England met physical activity guidelines in 2012.4 Active modes of transportation, including public transportation, can contribute substantially to total physical activity.5 Among working-age adults, commuting by public transportation increases physical activity levels6 and can improve health,7–9 but evidence about older people is sparse.The UK older people’s bus pass (“bus pass” herein) enables people of the state retirement age for women (previously 60 years) and older to travel free of charge on local buses, anywhere in the country.10 To our knowledge, this nationwide policy of free bus transportation for older people, irrespective of financial circumstances, is unique. The bus pass was introduced in Scotland in 2002, England and Wales in 2006, and Northern Ireland in 2008, with concessionary policies operating previously. There remain various additional local benefits; for instance, older people living in London are eligible for a Freedom Pass, which provides free travel on all public transportation.Of the forms of public transportation available in the United Kingdom, buses serve the widest range of communities; even the majority of very rural areas have some bus services. Buses operate over relatively short distances, transporting people between residential areas and urban centers, shopping areas, and hospitals. The bus pass is a widely recognized state benefit for older people often discussed in the media. Advice on obtaining a pass is offered by many organizations including older people’s charities and local authorities. The application form is short and simple, and can either be completed online or acquired locally—for example, from a Post Office or government offices.The aim of the bus pass is to “tackle social exclusion” among older people.11 Evidence suggests that it has been successful, providing opportunities for social interaction, giving a feeling of visibility and belonging, improving quality of life, reducing feelings of social exclusion, and improving access to services.12–14 The bus pass has been estimated to cost the UK government approximately £1 billion a year15 and the recent climate of austerity has led to suggestions that eligibility for the bus pass should be means tested, whereby only older people with income and wealth below a certain level would be eligible. However, many of the benefits derive, at least in part, from the universality of free bus travel for older people and the lack of stigma therefore associated with the pass.12,13In addition to the benefits to older people’s social inclusion, there may be unanticipated benefits of the bus pass—for instance, to physical health. We have previously shown that the bus pass is linked to increased walking frequency16 and reduced obesity17; however, it has not been possible to investigate these relationships directly or in detail. We hypothesized that older people who hold bus passes will be more physically active and will have better physical functioning and lower adiposity. We contend that, if these hypothesized relationships are observed, this would indicate that the bus pass helps enable healthier aging, which leads to health care expenditure savings that may mitigate the cost of providing the bus pass to older people.We used data from the English Longitudinal Study of Ageing (ELSA) to determine (1) among those eligible, who takes up the bus pass; (2) what factors are associated with frequency of bus use among those who have a bus pass; (3) whether having a bus pass is associated with how often people use any public transportation; and (4) whether having a bus pass is associated with physical activity levels, gait speed, and adiposity.     

Impact of expanded access to combination antiretroviral therapy in pregnancy: results from a cohort study in Ukraine

Objective

To investigate the scale-up of antenatal combination antiretroviral therapy (cART) in Ukraine since this became part of the national policy for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV).

Methods

Data on 3535 HIV-positive pregnant women who were enrolled into the Ukraine European Collaborative Study in 2008–2010 were analysed. Factors associated with receipt of zidovudine monotherapy (AZTm) – rather than cART – and rates of mother-to-child transmission (MTCT) of HIV were investigated.

Findings

cART coverage increased significantly, from 22% of deliveries in 2008 to 61% of those in 2010. After adjusting for possible confounders, initiation of antenatal AZTm – rather than cART – was associated with cohabiting (versus being married; adjusted prevalence ratio, aPR: 1.09; 95% confidence interval, CI: 1.02–1.16), at least two previous live births (versus none; aPR: 1.22; 95% CI: 1.11–1.35) and a diagnosis of HIV infection during the first or second trimester (versus before pregnancy; aPR: 1.11; 95% CI: 1.03–1.20). The overall MTCT rate was 4.1% (95% CI: 3.4–4.9); 42% (49/116) of the transmissions were from the 8% (n = 238) of women without antenatal ART. Compared with AZTm, cART was associated with a 70% greater reduction in the risk of MTCT (adjusted odds ratio: 0.30; 95% CI: 0.16–0.56).

Conclusion

Between 2008 and 2010, access to antenatal cART improved substantially in Ukraine, but implementation of the World Health Organization’s Option-B policy was slow. For MTCT to be eliminated in Ukraine, improvements in the retention of women in HIV care and further roll-out of Option B are urgently needed.     

10?Years Later: Changes in Food Access Disparities in New Orleans since Hurricane Katrina

Inadequate access to healthy food is a problem in many urban neighborhoods, particularly for racial-ethnic minorities and low-income groups who are more likely to reside in food deserts. Although substantial research throughout the country has documented the existence of these disparities, few studies have focused on how this access changes over time or is affected by environmental shocks. This study examined citywide supermarket access in New Orleans as well as racial-ethnic disparities in this access, prior to Hurricane Katrina and at three times afterwards. On-the-ground verification of supermarket locations was conducted in 2004–2005, 2007, 2009, and 2014 and was mapped with secondary demographic data. Census tracts were defined as predominantly African-American neighborhoods if 80 % or more of the population identified as such. HLM Poisson regression analyses were conducted in 2014 to identify the difference in likelihood of finding supermarkets in a neighborhood by race-ethnicity and across all years of interest. Racial-ethnic disparities existed before the storm and worsened after it (IRR = 0.35; 95 % CI = 0.21, 0.60). Improvements in disparities to pre-storm levels were not seen until 2009, 4 years after the storm. By 2014, supermarket access, on average, was not significantly different in African-American neighborhoods than in others (IRR = 0.90; 95 % CI = 0.65, 1.26). The slow recovery of New Orleans’ retail food infrastructure after Hurricane Katrina highlights the need for an increased focus on long-term planning to address disparities, especially those that may be exaggerated by shocks.     

The COVID-19 Pandemic as a Threat Multiplier for Childhood Health Disparities: Evidence from St. Louis,MO

The COVID-19 pandemic has highlighted socioeconomic and racial health disparities in the USA. In this study, we examined the COVID-19 pandemic as a threat multiplier for childhood health disparities by evaluating health behavior changes among urban St. Louis, MO, children (ages 6–14) during the COVID-19 pandemic. From 27 October to 10 December 2020, 122 parents/guardians reported on their children’s health behaviors (Eating, Sleeping, Physical activity, Time outside, Time with friends in-person, Time with friends remotely, Time using media for educational proposes, Time using media for non-educational proposes, and Social connectedness) prior to and during the COVID-19 pandemic. We ran K-means cluster analyses to identify distinct health behavior cluster profiles. Relative risks were determined to evaluate behavioral differences between the two clusters. Two distinct cluster profiles were identified: a High Impact profile (n = 49) and a Moderate Impact profile (n = 73). Children in the High Impact cluster had a greater risk of being diagnosed with COVID-19, developed worsened eating habits (RR = 2.10; 95% CI = 1.50–2.93), spent less time sleeping, and spent less time outdoors (RR = 1.55; 95% CI = 1.03–2.43) than the Moderate Impact cluster. The High Impact cluster was more likely to include Black children and children from single-adult households than the Moderate Impact cluster (both p < 0.05). Our findings suggest that the COVID-19 pandemic may be a threat multiplier for childhood health disparities. Further research is needed to better understand the long-term effects of the COVID-19 pandemic on children’s health.     

HIV/AIDS Surveillance Data for New York City West Indian–Born Blacks: Comparisons With Other Immigrant and US-Born Groups

Objectives. Although the risk of HIV among New York City West Indian–born Black immigrants often is assumed to be high, population-based data are lacking, a gap we aimed to address.Methods. Using 2006–2007 HIV/AIDS surveillance data from the New York City Department of Health and Mental Hygiene and population data from the US Census American Community Survey 2007, we compared the rate of newly reported HIV diagnoses, prevalence of people living with HIV/AIDS, and distribution of transmission risk categories in West Indian–born Blacks, 2 other immigrant groups, and US-born Blacks and Whites.Results. The age-adjusted rate of newly reported HIV diagnoses for West Indian–born Blacks was 43.19 per 100 000 (95% confidence interval [CI] = 38.92, 49.10). This was higher than the rate among US-born Whites (19.96; 95% CI = 18.63, 21.37) and Dominican immigrants and lower than that among US-born Blacks (109.48; 95% CI = 105.02, 114.10) and Haitian immigrants. Heterosexual transmission was the largest risk category in West Indian–born Blacks, accounting for 41% of new diagnoses.Conclusions. Although much lower than in US-born Blacks, the rate of newly reported HIV diagnoses in West Indian–born Blacks exceeds that among US-born Whites. Additional work is needed to understand the migration-related sources of risk.Immigrants from English-speaking Caribbean basin countries, often referred to as the West Indians, have been migrating to the United States for many decades, and they and their descendants constitute a large and culturally significant population in major Eastern seaboard cities, including New York City (NYC). The majority (81%) identify as Black, with a significant minority identifying as East Indian.1 Considering only those who are first-generation immigrants, the latest estimates (2007–2008) show that West Indians represent 21% of foreign-born persons in NYC and almost 25% of the NYC Black population.2 Despite the size of this immigrant group, in HIV/AIDS surveillance reports they have not been disaggregated from all Blacks nor from the Caribbean-born population overall, although some data suggest their HIV risk may be high.3     

Route Infrastructure and the Risk of Injuries to Bicyclists: A Case-Crossover Study

Objectives. We compared cycling injury risks of 14 route types and other route infrastructure features.Methods. We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip.Results. Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9).Conclusions. The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.Bicycling is an active mode of transportation with a range of individual and public health benefits.1–5 However, bicycling is underused for transportation in Australia, Canada, Ireland, the United States, and the United Kingdom, constituting an estimated 1% to 3% of trips, compared with 10% to 27% of trips in Denmark, Germany, Finland, the Netherlands, and Sweden.6–8 The reasons for low bicycle share of trips are multifaceted, but safety is one of the most frequently cited deterrents.9–11 These concerns are well founded: bicycling injury rates are higher in countries where cycling for transportation is less common.8,12,13To reduce bicycling injuries, the first step is to understand the determinants of risk. Studies in many English-speaking countries have focused on head injury reductions afforded by helmets.14–17 However, helmet use cannot explain the risk difference because helmets are rarely used in the European countries with lower injury rates.8,18,19 Typical route infrastructure (physical transportation structures and facilities) in countries with low bicycle share of trips differs from that in countries with high trip shares. In Germany, Denmark, and the Netherlands, bicycle-specific infrastructure is frequently available,20 so this is a promising avenue for investigating injury risks. In a review of route infrastructure and injury risk,21 we found some evidence that bicycle-specific infrastructure was associated with reduced risk. However, the studies reviewed had problems that have compromised confidence in the results: grouping of route categories that may have different risks, unclear definitions of route infrastructure, and difficulty controlling for characteristics of cyclists and for exposure to various route types. Debates continue about the contribution of route design to safety and about the safety of various route types.12,13,20,21Here we present a study designed to overcome these limitations.22 We examined injury risk of 14 route types using a case-crossover design in which injured participants served as their own controls. The design compared route characteristics at the location where the injury event occurred to those at a randomly selected point on the same trip route where no injury occurred. By randomly selecting the control site in this way, the probability that a specific infrastructure type would be chosen was proportional to its relative length on the trip (e.g., on a 4-km trip, there would be a 25% chance of selecting a control site on a 1-km section that was on a bike path). Because comparisons were within-trip, personal characteristics such as age, gender, and propensity for risk-taking behavior were matched, as were trip conditions such as bicycle type, clothing visibility, helmet use, weather, and time of day. This allowed the comparisons to focus on between-site infrastructure differences.