Experiences of distress and gaps in government safety net supports among parents of young children during the COVID-19 pandemic: a qualitative study.

BACKGROUND: The COVID-19 pandemic prompted rapid federal, state, and local government policymaking to buffer families from the health and economic harms of the pandemic. However, there has been little attention to families' perceptions of whether the pandemic safety net policy response was adequate, and what is needed to alleviate lasting effects on family well-being. This study examines the experiences and challenges of families with low incomes caring for young children during the pandemic. METHODS: Semi-structured qualitative interviews conducted from August 2020 to January 2021 with 34 parents of young children in California were analyzed using thematic analysis. RESULTS: We identified three key themes related to parents' experiences during the pandemic: (1) positive experiences with government support programs, (2) challenging experiences with government support programs, and (3) distress resulting from insufficient support for childcare disruptions. Participants reported that program expansions helped alleviate food insecurity, and those attending community colleges reported accessing a range of supports through supportive counselors. However, many reported gaps in support for childcare and distance learning, pre-existing housing instability, and parenting stressors. With insufficient supports, additional childcare and education workloads resulted in stress and exhaustion, guilt about competing demands, and stagnation of longer-term goals for economic and educational advancement. CONCLUSIONS: Families of young children, already facing housing and economic insecurity prior to the pandemic, experienced parental burnout. To support family well-being, participants endorsed policies to remove housing barriers, and expand childcare options to mitigate job loss and competing demands on parents. Policy responses that either alleviate stressors or bolster supports have the potential to prevent distress catalyzed by future disasters or the more common destabilizing experiences of economic insecurity.

Understanding the Predictors of Low Take-Up of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): A Nationwide Longitudinal Study.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is among the largest U.S. social safety net programs. Although strong evidence exists regarding the benefits of WIC, take-up (i.e., participation among eligible individuals) has steadily declined in the past decade. This study addresses gaps in our knowledge regarding predictors of WIC take-up during this time. METHODS: Data were drawn from the 1998-2017 waves of the National Health Interview Study (NHIS), a serial cross-sectional study of the U.S. POPULATION: The analytic sample included 23,645 children and 10,297 women eligible for WIC based on self-reported demographic characteristics. To investigate predictors of WIC take-up, we regressed self-reported WIC receipt on a range of individual-level predictors (e.g., age, nativity, income) and state- level predictors (e.g., unemployment rate, governor's political affiliation) using multivariable logistic regression. In secondary analyses, results were additionally stratified by race/ethnicity, time period, and age (for children). RESULTS: For both women and children, older maternal age and higher educational attainment were associated with decreased take-up of WIC. Associations differed by race/ethnicity, time period, and state characteristics including caseload of other social programs (e.g., Medicaid). DISCUSSION: Our study identifies groups that are less likely to take up WIC benefits for which they are eligible, thereby contributing important evidence to inform programs and policies to increase WIC participation among groups with lower take-up. As WIC evolves past the COVID-19 pandemic, special attention will be needed to ensure that resources to encourage and support the participation of racially and economically marginalized individuals are equitably distributed.

The Pent-Up Demand for Breastfeeding Among US Women: Trends After COVID-19 Shelter-in-Place.

Objectives. To estimate changes in national breastfeeding trends immediately before and after COVID-19‒related workplace closures in early 2020. Methods. The implementation of shelter-in-place policies in early 2020, when 90% of people in the United States were urged to remain at home, represents a unique natural experiment to assess the pent-up demand for breastfeeding among US women that may be stymied by the lack of a national paid leave policy. We used the 2017-2020 Pregnancy Risk Assessment Monitoring System (n = 118 139) to estimate changes in breastfeeding practices for births occurring before and after shelter-in-place policies were implemented in the United States. We did this in the overall sample and by racial/ethnic and income subgroups. Results. There was no change in breastfeeding initiation and a 17.5% increase in breastfeeding duration after shelter-in-place, with lingering effects through late 2020. High-income and White women demonstrated the largest gains. Conclusions. The United States ranks worse than similar countries when it comes to breastfeeding initiation and duration. This study suggests that this is partly attributable to inadequate access to postpartum paid leave. This study also demonstrates inequities introduced by patterns of remote work during the pandemic. (Am J Public Health. 2023;113(8):870-873. https://doi.org/10.2105/AJPH.2023.307313).

Racial and sociodemographic predictors of COVID-19 compared with influenza, appendicitis, and all-cause hospitalization: retrospective cohort analysis.

OBJECTIVE: To determine whether inequities in COVID-19 infection and hospitalization differ from those for common medical conditions: influenza, appendicitis, and all-cause hospitalization. DESIGN: Retrospective study based on electronic health records of three healthcare systems in San Francisco (university, public, and community) examining (1) racial/ethnic distribution in cases and hospitalization among patients with diagnosed COVID-19 (March-August 2020) and patients with diagnosed influenza, diagnosed appendicitis, or all-cause hospitalization (August 2017-March 2020), and (2) sociodemographic predictors of hospitalization among those with diagnosed COVID-19 and influenza. RESULTS: Patients 18 years or older with diagnosed COVID-19 (N = 3934), diagnosed influenza (N = 5932), diagnosed appendicitis (N = 1235), or all-cause hospitalization (N = 62,707) were included in the study. The age-adjusted racial/ethnic distribution of patients with diagnosed COVID-19 differed from that of patients with diagnosed influenza or appendicitis for all healthcare systems, as did hospitalization from these conditions compared to any cause. For example, in the public healthcare system, 68% of patients with diagnosed COVID-19 were Latine, compared with 43% of patients with diagnosed influenza, and 48% of patients with diagnosed appendicitis (p < 0.05). In multivariable logistic regressions, COVID-19 hospitalizations were associated with male sex, Asian and Pacific Islander race/ethnicity, Spanish language, and public insurance in the university healthcare system, and Latine race/ethnicity and obesity in the community healthcare system. Influenza hospitalizations were associated with Asian and Pacific Islander and other race/ethnicity in the university healthcare system, obesity in the community healthcare system, and Chinese language and public insurance in both the university and community healthcare systems. CONCLUSIONS: Racial/ethnic and sociodemographic inequities in diagnosed COVID-19 and hospitalization differed from those for diagnosed influenza and other medical conditions, with consistently higher odds among Latine and Spanish-speaking patients. This work highlights the need for disease-specific public health efforts in at-risk communities in addition to structural upstream interventions.

Unreported SARS-CoV-2 Home Testing and Test Positivity.

This cohort study examines time trends in officially reported SARS-CoV-2 case counts and unreported home test positivity.

Effects Of The 2021 Expanded Child Tax Credit On Adults' Mental Health: A Quasi-Experimental Study.

The US Congress temporarily expanded the Child Tax Credit (CTC) during the COVID-19 pandemic to provide economic assistance for families with children. Although formerly the CTC provided $2,000 per child for mostly middle-income parents, during July-December 2021 it provided up to $3,600 per child. Eligibility criteria were also expanded to reach more economically disadvantaged families. There has been little research evaluating the effect of the policy expansion on mental health. Using data from the Census Bureau's Household Pulse Survey and a quasi-experimental study design, we examined the effects of the expanded CTC on mental health and related outcomes among low-income adults with children, and by racial and ethnic subgroup. We found fewer depressive and anxiety symptoms among low-income adults. Adults of Black, Hispanic, and other racial and ethnic backgrounds demonstrated greater reductions in anxiety symptoms compared to non-Hispanic White adults with children. There were no changes in mental health care use. These findings are important for Congress and state legislators to weigh as they consider making the expanded CTC and other similar tax credits permanent to support economically disadvantaged families.

Understanding Take-Up Of The Earned Income Tax Credit Among Californians With Low Income.

The Earned Income Tax Credit (EITC) is the largest poverty alleviation program for families with children in the US, and it has well-documented health effects. However, not all eligible families receive benefits. The Assessing California Communities' Experiences with Safety Net Supports (ACCESS) Study interviewed 411 EITC-eligible Californians with young children to understand low take-up of the federal EITC and California's supplemental CalEITC. Interviews were conducted in English and Spanish in 2020 and 2021 to gather information on sociodemographic characteristics, tax filing, and EITC receipt (verified via tax forms). Among those eligible for the EITC or CalEITC, 9 percent of participants did not file taxes; among those who did file taxes, about 84 percent received the EITC, and 83 percent received the CalEITC. Lower likelihood of federal EITC receipt among those eligible and filing taxes was associated with being younger, not speaking English, and not having prior knowledge of the EITC. Lower likelihood of CalEITC receipt among those eligible and filing taxes was associated with not speaking English. These findings can inform policies and community interventions to increase EITC take-up and thereby help address health equity.

Social and Economic Factors Related to Healthcare Delay Among Low-Income Families During COVID-19: Results from the ACCESS Observational Study.

Delayed medical care is a negative consequence of the COVID-19 pandemic for families with young children. Our study used data from the Accessing California Communities' Experiences with Safety net Supports (ACCESS) survey, a cross-sectional study that assessed experiences with safety-net programs among working families with low incomes (n=491). From August 2020 to May 2021, we conducted interviewer-administered surveys of low-income families with young children (ages zero to eight) in California and asked questions about whether participants had delayed medical care for their children or themselves. We found that delaying care for children was associated with lack of childcare and with the child having pre-existing conditions. Delaying parental medical care was associated with lack of childcare, experiences of racism, government mistrust, and perceptions of welfare stigma. These results suggest that health care access may be improved through a focus on supporting childcare systems and addressing structural racism.

Effects of the revised WIC food package on women's and children's health: a quasi-experimental study.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was revised in 2009 to be more congruent with national dietary guidelines. There is limited research examining effects of the revision on women's and children's health. The objective of this study was to evaluate whether the revised WIC food package was associated with various indicators of physical and mental health for women and children. METHODS: We used 1998-2017 waves of the National Health Interview Survey (N = 81,771 women and 27,780 children) to estimate effects of the revised WIC food package on indicators of health for both women (self-reported health and body mass index) and children (anemia, mental health, and parent-reported health). We used difference-in-differences analysis, a quasi-experimental technique that assessed pre-post differences in outcomes among WIC-recipients while "differencing out" the secular underlying trends among a control group of non-recipients. RESULTS: For all outcomes evaluated for women and children, we were unable to rule out the null hypothesis that there was no effect of receiving the revised WIC food package. These findings were confirmed across several secondary analyses conducted to assess heterogeneity of effects and robustness of results. CONCLUSION: While we did not find effects of the revised WIC food package on downstream health indicators, studies using similarly robust methods in other datasets have found shorter-term effects on more proximal outcomes related to diet and nutrition. Effects of the modest WIC revisions may be less impactful on longer-term indicators of health, and future studies should examine the larger COVID-19-era expansion.

Pandemic-related socioeconomic disruptions and adverse health outcomes: a cross-sectional study of female caregivers.

BACKGROUND: The COVID-19 pandemic and efforts to mitigate transmission resulted in sudden and widespread socioeconomic disruptions including school and child care closures, unemployment and underemployment, and housing precarity. Understanding the extent to which these disruptions may have contributed to adverse health outcomes is critical for establishing policy priorities that can mitigate further harm. METHODS: We explored the associations between pandemic-related child care, employment, and housing disruptions with depressive symptoms, self-rated health, and food security status among a sample of economically disadvantaged and racially diverse female caregivers of young children (n=464). Data were derived from the Assessing California Communities' Experiences with Safety Net Supports (ACCESS) study, which conducted survey-based interviews with California caregivers with low-income from August 2020 - May 2021. We implemented a series of multivariable Poisson regressions with robust standard errors to assess the potency of each exposure, independently and within the context of one another. RESULTS: Most caregivers experienced disruptions to child care (70%) and employment (63%); few experienced major housing disruptions (8%). Women that experienced child care and housing disruptions had greater depressive symptoms, lower self-rated health, and greater food insecurity, although the relationships for housing and depressive symptoms were modified by the timing of participants' interviews. Employment disruptions were not associated with any of the examined adverse health outcomes. CONCLUSION: In the wake of socioeconomic stressors brought about by the COVID-19 pandemic, attending to structural deficits in the child care system and increasing housing supports may be critical for protecting the health of caregivers.

The U.S. COVID-19 County Policy Database: a novel resource to support pandemic-related research.

BACKGROUND: It is increasingly recognized that policies have played a role in both alleviating and exacerbating the health and economic consequences of the COVID-19 pandemic. There has been limited systematic evaluation of variation in U.S. local COVID-19-related policies. This study introduces the U.S. COVID-19 County Policy (UCCP) Database, whose objective is to systematically gather, characterize, and assess variation in U.S. county-level COVID-19-related policies. METHODS: In January-March 2021, we collected an initial wave of cross-sectional data from government and media websites for 171 counties in 7 states on 22 county-level COVID-19-related policies within 3 policy domains that are likely to affect health: (1) containment/closure, (2) economic support, and (3) public health. We characterized the presence and comprehensiveness of policies using univariate analyses. We also examined the correlation of policies with one another using bivariate Spearman's correlations. Finally, we examined geographical variation in policies across and within states. RESULTS: There was substantial variation in the presence and comprehensiveness of county policies during January-March 2021. For containment and closure policies, the percent of counties with no restrictions ranged from 0% (for public events) to more than half for public transportation (67.8%), hair salons (52.6%), and religious gatherings (52.0%). For economic policies, 76.6% of counties had housing support, while 64.9% had utility relief. For public health policies, most were comprehensive, with 70.8% of counties having coordinated public information campaigns, and 66.7% requiring masks outside the home at all times. Correlations between containment and closure policies tended to be positive and moderate (i.e., coefficients 0.4-0.59). There was variation within and across states in the number and comprehensiveness of policies. CONCLUSIONS: This study introduces the UCCP Database, presenting granular data on local governments' responses to the COVID-19 pandemic. We documented substantial variation within and across states on a wide range of policies at a single point in time. By making these data publicly available, this study supports future research that can leverage this database to examine how policies contributed to and continue to influence pandemic-related health and socioeconomic outcomes and disparities. The UCCP database is available online and will include additional time points for 2020-2021 and additional counties nationwide.

Characterizing the Landscape of Safety Net Programs and Policies in California during the COVID-19 Pandemic.

The COVID-19 pandemic prompted rapid and innovative policymaking around the world at the national, regional, and local levels. There has been limited work to systematically document and characterize new and expanded local U.S. pandemic-era policies, which is imperative to better understand the policy variation and resulting health impacts during this unprecedented time. California, the most populous U.S. state, provides a case example of a particularly active policy response. The aim of this Brief Report is to summarize the creation and potential areas of application of a newly created publicly available California- and US-based COVID-19 policy database. We generated an extensive list of California and US policies that were modified or created in response to the COVID-19 pandemic. From July-November 2021, we searched current and historical California and federal government websites, press releases, social media, and news sources and recorded detailed information on these policies, including coverage dates, eligibility criteria, and benefit amounts. This comprehensive dataset includes 39 public health, economic, housing, and safety net programs and policies implemented at both federal and state levels and provides details of the complex and multifaceted policy landscape in California from March 2020 to November 2021. Our database is publicly available. Future investigators can leverage the information systematically recorded in this database to rigorously assess the short- and long-term effects of these policies, which will in turn inform future preparedness response plans in California and beyond.

Association of US state policy orientation with adverse birth outcomes: a longitudinal analysis.

BACKGROUND: The current US context is marked by extreme right-left partisanship, which means that state policies tend to bundle together and are not experienced in isolation. While prior work has leveraged abrupt shifts in single policies to examine the effects of state policy on birth outcomes, we examined a holistic measure that captures political polarisation. METHODS: Data were drawn from national birth certificates for 2003-2017 (N=56 770 470). Outcomes included preterm birth, low birth weight, small-for-gestational age and other perinatal health measures. The primary exposure was a composite index of right-left state policy orientation, generated from historical data on 135 state policies. Multivariable regressions were used to estimate the association between state policy orientation and each outcome, adjusting for relevant covariates. RESULTS: Compared with infants born in states with right-leaning policy orientations, those born in left-leaning states had lower odds of adverse birth outcomes (eg, low birth weight: OR 0.95 (0.93, 0.97), preterm birth: OR 0.94 (0.92, 0.95)). Subgroup analyses revealed stronger associations for US-born and White mothers. With the inclusion of state fixed effects, left-leaning policy orientation was no longer associated with lower odds of adverse birth outcomes. Models were otherwise robust to alternative specifications. CONCLUSION: While left-leaning state policy orientation has protective associations with a range of birth outcomes, the associations may be explained by stable characteristics of states, at least during the study period. Future studies should examine state policy orientation in association with other health outcomes and study periods.

The effects of state earned income tax credits on mental health and health behaviors: A quasi-experimental study.

The earned income tax credit (EITC) is the largest U.S. poverty alleviation program for families with children, and state EITC policies provide a modest supplement to the federal program. Yet there are few studies of the effects of state EITC policies on population health. We examined whether state EITC policies affect mental health and health behaviors. Participants were drawn from the 1995-2015 waves of the Panel Study of Income Dynamics, a diverse national cohort study (N = 10,567). We used a quasi-experimental difference-in-differences analysis to examine the effects of state EITC programs among eligible individuals, accounting for secular trends among similar individuals in non-EITC states. Outcomes included self-reported general health, psychological distress, alcohol use, and smoking. The mean size of state EITC refunds in our sample was $265 for eligible individuals. In the overall sample, state EITC programs were not associated with any health outcomes of interest. This finding was robust to alternative specifications, and similar in subgroup analyses by gender and marital status. This study suggests that state EITC programs, which tend to provide smaller refunds than the federal program, may not be large enough to have a positive impact on mental health and health behaviors. These findings may inform policymaking related to the generosity of state EITC programs, especially as states seek to address the socioeconomic consequences of the COVID-19 pandemic.