Depressive symptoms associated with psychological correlates of physical activity and perceived helpfulness of intervention features

The anti-depressive benefits of physical activity are well-evidenced; however little is known about whether people with more frequent depressive symptoms have different psychological correlates of physical activity than people with less frequent symptoms, or whether special consideration is needed in targeting web-based physical activity interventions toward people with frequent depressive symptoms. An online cross-sectional survey was used to collect data from 511 adults (age = 45.99 ± 14.73 years). Two multiple regression analyses were conducted to test the relationship between frequency of depressive symptoms and (1) psychological correlates of physical activity (i.e., intentions, perceived behavioral control, affective attitudes, instrumental attitudes, and perceived physical activity effectiveness), and (2) perceived helpfulness of a variety of web-based physical activity intervention features. People with more frequent depressive symptoms had lower perceived behavioral control of physical activity (β = −0.19), were more likely to report that goal-setting intervention tools (β = 0.10) and personally-relevant information (β = 0.09) would be helpful, and were less likely to report intervention features portraying information about how similar people are being regularly active as helpful (β = −0.10) than those with less frequent symptoms. These findings highlight key components for designing web-based physical activity intervention content for people with depressive symptoms.     

Is Depression Associated with Contraceptive Motivations,Intentions, and Use Among a Sample of Low-Income Latinas?

BackgroundLatinas in the United States experience high rates of unintended pregnancy and low rates of contraception use, yet reasons are not completely understood. Depression is common among pregnant and nonpregnant Latinas; its influence on contraceptive motivations, intentions, and use is understudied.ObjectivesWe sought to 1) describe Latinas' contraceptive motivations, intentions, and use; 2) use structural equation modeling to test associations between depression and contraceptive self-efficacy/motivations/intentions/use; and 3) determine whether associations differ by pregnancy status.MethodsThis cross-sectional study included Latinas ages 15 to 45 recruited from an urban Federally Qualified Health Center in Baltimore, Maryland. Structured surveys were used to collect data regarding depressive symptoms measured using the PHQ-9. All other constructs were measured with previously validated questions. Constructs included contraceptive self-efficacy, positive and negative contraceptive motivations (perceived advantages and disadvantages of using contraception), contraceptive intentions to begin or continue contraception use, and contraceptive methods currently used.ResultsAmong pregnant Latinas, depression was associated with negative motivations (β = 0.16; p < .05), negative motivations were associated with intentions (β = ?0.22; p < .01), and contraceptive self-efficacy was associated with intentions (β = 0.43; p < .001). Among nonpregnant Latinas, contraceptive self-efficacy was associated with intentions (β = 0.78; p < .001) and intentions were associated with use (β = 0.40; p < .05).ConclusionsAmong pregnant Latinas, negative motivations intervene in the association between depression and contraceptive intentions. For nonpregnant Latinas, intentions intervene in the association between self-efficacy and contraceptive use. This study underscores the importance of depression screening during pregnancy and encourages practitioners to target contraceptive motivations to improve contraceptive use.     

Living Independent From Tobacco reduces cigarette smoking and improves general health status among long-term tobacco users with disabilities

BackgroundPeople with disabilities disproportionately use tobacco and suffer associated negative health consequences. Research is needed to explore tobacco cessation programming for people with disabilities to counter these health disparities.ObjectiveWe evaluated the impact of Living Independent From Tobacco on tobacco use, knowledge and attitudes about tobacco use, coping skills, and perceived health status among people with disabilities. We also assessed participants’ subjective impressions at post-test.MethodsLiving Independent From Tobacco was evaluated via train the trainer model at three Midwestern sites serving people with disabilities. Outcomes were assessed at four time points: pre- and post-test (n = 30), and again at 1-month (n = 26) and 6-months (n = 13).ResultsLong-term tobacco users with disabilities significantly reduced tobacco use from pre-test to post-test (p = 0.003), and, compared to baseline, this reduction continued to be significant 1-month after the intervention (p = 0.02). From pre-test to post-test, perceived health status significantly improved (p = 0.0001). No significant changes were observed across time points for knowledge and attitudes about tobacco use nor for coping skills. Qualitative data revealed the importance of coping skills to mitigate the negative effects of nicotine withdrawal. Peer accountability was also noted as an important source of motivation for tobacco cessation.ConclusionsData from the present study provide evidence for the short-term effectiveness of Living Independent From Tobacco to reduce tobacco use and improve health status among people with disabilities. Qualitative data revealed the importance of coping skills and peer accountability to support tobacco cessation. Implications for tobacco cessation programming for people with disabilities are discussed.     

Physical Morbidity and Mental Health Care Among Young People

PurposeThis epidemiological study examined associations between morbidity status and mental health care use among young people.MethodsData come from individuals aged 15–29 years (n = 5,630) in the Canadian Community Health Survey-Mental Health (2012). Physical health problems were measured using a standard checklist. The Composite International Diagnostic Interview assessed 12-month mental health and substance use problems. Individuals were asked which types of mental health care they had received in the past year. Logistic, ordinal, and multinomial regression models were computed and the method of variance estimates recovery was used to compare estimates.ResultsIndividuals with comorbid physical health problems had higher odds of mental health care use for those with mental (odds ratio [OR] = 12.54 [7.07, 22.25]) and substance use problems (OR = 2.97 [1.75, 5.05]). While these estimates were higher than for individuals without physical comorbidity, differences were not statistically significant. For mental health care needs not being met, associations were found for individuals with mental (OR = 2.56 [1.24, 5.26]) or substance use problems only (OR = 2.48 [1.06, 5.82]).ConclusionsOdds of perceiving the need for and using mental health care were high in individuals with a physical comorbidity, but similar to those with mental health or substance use problems only. Young people with a physical comorbidity were less likely to report that their mental health needs are not being met compared to those with mental health or substance use problems only. Research is needed to understand barriers and facilitators faced by young people with mental health or substance use problems as they navigate the health system.     

Longitudinal associations between changes in screen-time and mental health outcomes in adolescents

IntroductionThe primary aim was to examine longitudinal associations between changes in screen-time and mental health outcomes among adolescents.MethodsAdolescents (N = 322, 65.5% females, mean age = 14.4 ± 0.6 years) reported screen-time and mental health at two time points over a school year. Multi-level linear regression analyses were conducted after adjusting for covariates.ResultsChanges in total recreational screen-time (β = −0.09 p = 0.048) and tablet/mobile phone use (β = −0.18, p < 0.001) were negatively associated with physical self-concept. Changes in total recreational screen-time (β = −0.20, p = 0.001) and computer use (β = −0.23, p = 0.003) were negatively associated with psychological well-being. A positive association was found with television/DVD use and psychological difficulties (β = 0.16, p = 0.015). No associations were found for non-recreational screen-time.ConclusionChanges in recreational screen-time were associated with changes in a range of mental health outcomes.     

Relationship between double COVID-19 vaccine uptake and trust in effectiveness and safety of vaccination in general in 23 Member states of the European Union: an ecological study

IntroductionThe aim of this study was to assess the relationship between double COVID-19 vaccine uptake and trust in effectiveness and safety of vaccination in general in 23 European Union (EU) countries.MethodsEcological study. Data was retrieved from the Flash Eurobarometer 494 and Our World in Data. We estimated Pearson’s correlation coefficients and fitted multiple linear regression models.ResultsThere is a negative linear correlation between the percentage of people doubly vaccinated and the percentage of low trust in vaccine effectiveness (r = -0.48, p-value = 0.021), and the percentage of low trust in vaccine safety (r = -0.43, p-value = 0.041). There is a negative adjusted relation between the percentage of low trust in vaccine safety and the percentage of people doubly vaccinated (aβ_{% low trust in vaccine safety}:-0.25; 95% CI: ?0.49,-0.01, p-value = 0.045).ConclusionAn increase in health literacy of people living in certain countries in the EU may be needed to boost COVID-19 vaccine uptake.     

Cues for Increasing Social Presence for Mobile Health App Adoption

As mobile health apps become increasingly influential in daily life, they present an important opportunity for health communication for disease prevention. User impressions of app designs are influential for adoption. Using cues to increase feelings of being with others (social presence) is one way to encourage favorable impressions and health app adoption. To examine the impact of social context cues (conversation cues vs. community cues vs. no cue control) on two forms of social presence (emergent and transcendent social presence), we conducted an online experiment (n = 587) with US adults. We also examined the indirect effects of conversation and community cues through social presence on app trust, perceived ease of use, perceived usefulness, and intentions to use the app. We found that conversational cues elicited intended feelings for new, emergent interactions and that community cues increased perceptions of ongoing or established social formations for transcendent interactions. These cues also had positive indirect effects for increased trust, perceived usefulness, and intentions to use the health apps and should be considered when developing mHealth to improve uptake and delivery of health promotion online.     

An exploratory study of fitness practitioner intentions toward exercise programming for individuals with multiple sclerosis

BackgroundIncreasing community practice that facilitates physical activity for people with multiple sclerosis (MS) is critical to improve health outcomes and enhance quality of life in this population.ObjectiveThe purpose of this exploratory study was to employ the Theory of Planned Behavior (TPB) in order to examine beliefs, attitudes and intentions of fitness practitioners (FPs) toward working with adults with MS in community-based fitness facilities. The study also aimed to assess the relative contribution of FP attributes on the best predictor of favorable intentions to work with individuals with MS.MethodPractitioners (N = 580) completed the Fitness Practitioner Survey via a web-based platform.ResultsThe FPs' intention to work with a club member with MS was best predicted by attitudes (R = .81, R² = .65, F_6,373 = 114.46, p < .001) and favorable attitude was best predicted by perceived competence (R = .52; R² = .27, F_9,338 = 14.18, p < .001).ConclusionPractitioners believed that, by working with a person with MS, both staff and other club members would benefit and that including an individual with MS into their practice was worth the effort. As well, the individual with MS would benefit by experiencing success, increasing functional independence, and having greater social interaction. Fitness practitioners who had more education, held various professional certifications associated with physical activity and fitness, and had prior positive quality experiences working with diverse populations reported higher perceived competence.     

Predictors of intention to vaccinate against COVID-19: Results of a nationwide survey

BackgroundPublic polling indicates that vaccine uptake will be suboptimal when COVID-19 vaccines become available. Formative research seeking an understanding of weak vaccination intentions is urgently needed.MethodsNationwide online survey of 804 U.S. English-speaking adults. Compensated participants were recruited from the U.S. through an internet survey panel of 2.5 million residents developed by a commercial survey firm. Recruitment was based on quota sampling to produce a U.S. Census-matched sample representative of the nation with regard to region of residence, sex, and age.ResultsCOVID-19 vaccination intentions were weak, with 14.8% of respondents being unlikely to get vaccinated and another 23.0% unsure. Intent to vaccinate was highest for men, older people, individuals who identified as white and non-Hispanic, the affluent and college-educated, Democrats, those who were married or partnered, people with pre-existing medical conditions, and those vaccinated against influenza during the 2019–2020 flu season.In a multiple linear regression, significant predictors of vaccination intent were general vaccine knowledge (β = 0.311, p < .001), rejection of vaccine conspiracies (β = ?0.117, p = .003), perceived severity of COVID-19 (β = 0.273, p < .001), influenza vaccine uptake (β = 0.178, p < .001), having ≥ 5 pre-existing conditions (β = 0.098, p = .003), being male (β = 0.119, p < .001), household income of ≥ $120,000 (β = 0.110, p = .004), identifying as a Democrat (β = 0.075, p < .029), and not relying upon social media for virus information (β = -0.090, p 〈0 0 2). Intent to vaccinate was lower for Fox News (57.3%) than CNN/MSNBC viewers (76.4%) (χ2 (1) = 12.68, p < .001). Political party differences in threat appraisals and vaccine conspiracy beliefs are described.ConclusionsDemographic characteristics, vaccine knowledge, perceived vulnerability to COVID-19, risk factors for COVID-19, and politics likely contribute to vaccination hesitancy.     

Perceived impacts of COVID-19 on wellbeing among US working-age adults with ADL difficulty

BackgroundThe COVID-19 pandemic has disproportionately impacted people with disabilities. Working-age adults with ADL difficulty may face unique challenges and heightened health risks because of the pandemic. It is critical to better understand the impacts of COVID-19 on social, financial, physical, and mental wellbeing among people with disabilities to inform more inclusive pandemic response policies.ObjectiveThis study compares perceived COVID-19 physical and mental health, social, and financial impacts for US working-age adults with and without ADL difficulty.MethodsWe analyzed data from a national survey of US working-age adults (aged 18–64) conducted in February and March 2021 (N = 3697). We used logistic regression to compare perceived COVID-19-related impacts on physical and mental health, healthcare access, social relationships, and financial wellbeing among those with and without ADL difficulty.ResultsAdults with ADL difficulty were more likely to report negative COVID-19 impacts for many but not all outcomes. Net of covariates, adults with ADL difficulty had significantly greater odds of reporting COVID-19 infection (OR = 2.1) and hospitalization (OR = 6.7), negative physical health impacts (OR = 2.0), and negative impacts on family relationships (OR = 1.6). However, they had significantly lower odds of losing a friend or family member to COVID-19 (OR = 0.7). There were no significant differences in perceived impacts on mental health, ability to see a doctor, relationships with friends, or financial wellbeing.ConclusionsWorking-age adults with ADL difficulty experienced disproportionate health and social harm due to the COVID-19 pandemic. To address these disparities, public health response efforts and social policies supporting pandemic recovery must include disability perspectives.     

Cigarettes versus water-pipes: Differences and similarities in factors predicting the use of cigarettes and water-pipes among young male adults according to the planned-behaviour theory

Cigarette and water-pipe smoking are responsible for substantial harmful health consequences. However, studies have often examined these two types of smoking in separate study samples. Thus, this study examined differences and similarities among factors predicting cigarette and water-pipe smoking according to planned-behaviour theory within the same sample. Two hundred and twenty-one young Arab Israeli male adults (N = 221) completed demographic, self-esteem and planned-behaviour questionnaires. The study findings demonstrated that perceived ability to control one's water-pipe use was significantly higher than perceived ability to control one's use of cigarettes. With regard to attitudes, norms and intentions, no significant differences were found between cigarette and water-pipe use. Hierarchal multiple regressions showed that being Muslim, self-esteem, negative attitudes and negative norms contributed to the explained variance of both cigarette and water-pipe smoking. Self-control contributed to the variance in cigarette smoking, but not water-pipe smoking. The findings make an important contribution to our understanding of the differences and similarities in the factors predicting cigarette and water-pipe use among young male adults. Theoretical and clinical implications are discussed.     

Depressive Symptoms Among Older Adults Pre– and Post–COVID-19 Pandemic

ObjectivesIt is a concern that public health measures to prevent older people contracting COVID-19 could lead to a rise in mental health problems such as depression.The aim of this study therefore is to examine trends of depressive symptoms before and during the COVID-19 pandemic in a large cohort of older people.DesignObservational study with 6-year follow-up.Setting & ParticipantsMore than 3000 community-dwelling adults aged ≥60 years participating in The Irish Longitudinal Study on Ageing (TILDA).MethodsMixed effects multilevel models were used to describe trends in depressive symptoms across 3 waves of TILDA: wave 4 (2016), wave 5 (2018), and a final wave conducted July-November 2020. Depressive symptoms were measured using the 8-item Center for Epidemiologic Studies Depression Scale (CES-D), with a score ≥9 indicating clinically significant symptoms.ResultsThe prevalence of clinically significant depressive symptoms at waves 4 and 5 was 7.2% [95% confidence interval (CI) 6.5, 7.9] and 7.2% (95% CI 6.5, 8.0), respectively. This more than doubled to 19.8% (95% CI 18.5, 21.2) during the COVID-19 pandemic. There was no change in CES-D scores between waves 4 and 5 (β = 0.09, 95% CI –0.04, 0.23), but a large increase in symptoms was observed during the pandemic (β = 2.20, 95% CI 2.07, 2.33). Age ≥70 years was independently associated with depressive symptoms (β = 0.45, 95% CI 0.18, 0.72) during the pandemic but not from wave 4 to 5 (β = 0.09, 95% CI –0.18, 0.36). Living with others was associated with a lower burden of symptoms during the pandemic (β = −0.40, 95% CI –0.71, −0.09) but not between waves 4 and 5 (β = −0.40, 95% CI –0.71, −0.09).Conclusions and ImplicationsThis study demonstrates significant increases in the burden of depressive symptoms among older people during the COVID-19 pandemic, particularly those aged ≥70 years and/or living alone. Even a small increase in the incidence of late life depression can have major implications for health care systems and societies in general. Improving access to age-attuned mental health care should therefore be a priority.     

Attitudes towards mental health,mental health research and digital interventions by young adults with type 1 diabetes: A qualitative analysis

Background

Young people with type 1 diabetes are at increased risk of mental disorders. Whereas treatment need is high, difficulty recruiting young people with type 1 diabetes into psychosocial studies complicates development, testing and dissemination of these interventions.

Objective

Interviews with young adults with type 1 diabetes were conducted to examine attitudes towards mental health and mental health research, including barriers and motivators to participation in mental health studies and preferred sources of mental health support. The interviews were audio‐taped, transcribed and evaluated via thematic analysis.

Setting and participants

Young adults with type 1 diabetes were recruited via social media channels of 3 advocacy organizations. A total of 31 young adults (26 females and 5 males) with an average age of 22 years were interviewed between October 2015 and January 2016.

Results

Participants were largely unaware of their increased vulnerability to common mental health problems and knew little about mental health research. Major barriers to participation included perceived stigma and lifestyle issues and low levels of trust in researchers. Opportunities to connect with peers and help others were described as key motivators. Psychological distress was considered normal within the context of diabetes. A need for some level of human contact in receiving psychosocial support was expressed.

Discussion and conclusion

Findings provide valuable insights into the complex dynamics of engaging young adults with type 1 diabetes in mental health studies. Interviewees provided practical suggestions to assist investigation and delivery of psychosocial interventions for this vulnerable group.     

Young Adults' COVID-19 Testing Intentions: The Role of Health Beliefs and Anticipated Regret

PurposeYoung adults are at high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and transmission due to their social behaviors. The purpose of this study was to determine their attitudes toward coronavirus disease 2019 (COVID-19) testing, an important approach for minimizing infection and transmission.MethodsOne hundred seventy eight US individuals aged 19–25 years completed an online survey measuring COVID-19 health beliefs and testing intentions. Multivariable logistic regression evaluated the association of heath belief measures (perceived COVID-19 susceptibility, COVID-19 severity, barriers and benefits to testing, and social concerns) with testing intentions.ResultsMost respondents (86.0%) intended to accept a COVID-19 test if recommended by a health professional. High social concern and low perceived obstacles were associated with intent to get tested.ConclusionsIn this sample, most young adults intended to accept COVID-19 testing. Health beliefs predicted testing intention and point to possible intervention approaches to increase willingness to accept COVID-19 testing.     

Post-adoption beliefs and continuance intention of smart device use among people with physical disabilities

BackgroundThere has been a continuous increase of smart device use among people with physical disabilities in Korea. In spite of previous research on those people’s motives to adopt smart devices, little investigation has been conducted to scrutinize post-adoption behaviors of using smart devices among people with physical disabilities.Objective/Hypothesis: Based on the post-adoption model, this study examined the relationship between post-adoption beliefs regarding smart devices and behavioral intentions toward continued use of smartphones among people with physical disabilities. Moreover, this study investigated the moderating effects of self-efficacy on the relationships among the main study variables.MethodsBoth online and paper-pencil surveys were conducted, resulting in a total of 108 questionnaires collected from people with physical disabilities.ResultsA path analysis showed that, with the exception of perceived ease of use, all variables (confirmation, perceived usefulness, and satisfaction of smart device use) had significant effects on continuance intention to use smart devices. Another main finding of this study was the significant moderating effects of general self-efficacy on the relationships among the three variables of confirmation, perceived usefulness, and continuance intention of smart devices. The relationships among the three variables were significantly stronger among people with lower levels of general self-efficacy.ConclusionsThis study’s main findings will aid the thorough comprehension of the mechanisms that lead people with physical disabilities to continue to use smart devices.     

Do Parents Still Matter? The Impact of Parents and Peers on Adolescent Electronic Cigarette Use

PurposeVaping among adolescents has reached epidemic levels. Identifying factors associated with electronic cigarette (e-cigarette) use initiation could inform prevention programming. This study examined whether parental attitudes toward e-cigarettes impacted adolescent e-cigarette use intentions, positive expectancies of use, and actual use when accounting for adolescent attitudes and peer norms. Parents' negative attitudes toward e-cigarettes were expected to reduce teen e-cigarette use intentions. Low e-cigarette use intentions were expected to mediate the association between parental attitudes and teen e-cigarette use. Peer norms were expected to be associated with positive expectancies. Positive expectancies were expected to mediate the association between peer norms and teen e-cigarette use.MethodsA sample of e-cigarette naïve adolescents (n = 176, aged 14–17 years, 52% female, 82% Latinx/Hispanic) and their parents were assessed. Parents and adolescents rated harm associated with e-cigarette use. Adolescents reported their perceptions of peer e-cigarette norms, intentions, positive expectancies, and e-cigarette use. Cross-sectional models were estimated for e-cigarette use intentions and positive expectancies. Prospective mediation models (n = 142) characterized pathways to e-cigarette use.ResultsParents' attitudes toward e-cigarettes were associated with weaker intentions. Intentions mediated the association between parental attitudes and e-cigarette use. Adolescents reporting favorable e-cigarette peer norms endorsed more positive expectancies. Positive expectancies did not mediate the association between peer norms and e-cigarette use.ConclusionsParents actively shape adolescent e-cigarette use even when accounting for peer norms and adolescent attitudes. Involving parents in prevention programming may help reduce vaping among teens. These associations should be examined with a larger and more diverse sample.     

Obesity stigmatization as the status quo: Structural considerations and prevalence among young adults in the U.S.

ObjectiveAlthough obesity stigmatization contributes to significant health, economic, and quality-of-life challenges for U.S. adults, the prevalence and nature of stigmatizing attitudes requires an update and clarification. The present study sought to examine the prevalence and major dimensions of negative attitudes toward obesity through assessment of young U.S. adults' responses to the Attitudes Toward Obese Persons Scale.MethodParticipants were women (n = 578) and men (n = 233) who completed self-report questionnaires assessing obesity stigmatization and eating disorder features.ResultsResults indicate that at least one stigmatizing attitude was endorsed by 92.5% of respondents, with an average endorsement rate of 32.8% across items. Eating disorder features, body size, and gender were not related to one's likelihood of endorsing negative attitudes toward obesity. Distinct clusters of negative attitudes were identified involving beliefs that “obese people suffer” and “obese people are inferior.”DiscussionData suggest that large proportions of young U.S. adults harbor negative attitudes toward obese persons and these attitudes are pervasive across individuals with different characteristics. Although such negative attitudes have traditionally been conceptualized as relatively unidimensional, results suggest that future research would benefit from deconstructing negative attitudes into those related to pitying the obese and those related to perceiving the obese with harsh judgment.     

Do social support and community engagement act as mechanisms in the association between neighbourhood income inequality and the mental health of mothers in Calgary,Canada? A mediation analysis

PurposeAccording to the social determinants of health framework, income inequality is a potential risk factor for adverse mental health. However, few studies have explored the mechanisms suspected to mediate this relationship. The current study addresses this gap through a mediation analysis to determine if social support and community engagement act as mediators linking neighbourhood income inequality to maternal anxiety and depressive symptoms within a cohort of new mothers living in the City of Calgary, Canada.MethodsData collected at three years postpartum from mothers belonging to the All Our Families (AOF) cohort were used in the current study. Maternal data were collected between 2012 and 2015 and linked to neighbourhood socioeconomic data from the 2006 Canadian Census. Income inequality was measured using Gini coefficients derived from 2006 after-tax census data. Generalized structural equation models were used to quantify the associations between income inequality and mental health symptoms, and to assess the potential direct and indirect mediating effects of maternal social support and community engagement.ResultsIncome inequality was not significantly associated with higher depressive symptoms (β = 0.32, 95%CI = −0.067, 0.70), anxiety symptoms (β = 0.11, 95%CI = −0.39, 0.60), or lower social support. Income inequality was not associated with community engagement. For the depression models, higher social support was significantly associated with lower depressive symptoms (β = −0.13, 95%CI = −0.15, −0.097), while community engagement was not significantly associated with depressive symptoms (β = 0.059, 95%CI = −0.15, 0.27). Similarly, for the anxiety models, lower anxiety symptoms were significantly associated with higher levels of social support (β = −0.17, 95%CI = −0.20, −0.13) but not with higher levels of community engagement (β = 0.14, 95%CI = −0.14, 0.41).ConclusionThe current study did not find clear evidence for social support or community engagement mediating the relationship between neighbourhood income inequality and maternal mental health. Future investigations should employ a broader longitudinal approach to capture changes in income inequality, potential mediators, and mental health symptomatology over time.