Understanding the pathways leading to socioeconomic inequalities in HIV testing uptake in 18 sub-Saharan African countries.

OBJECTIVE: To better understand the different pathways linking socioeconomic position and HIV testing uptake in 18 sub-Saharan African countries. DESIGN: We used cross-sectional population-based surveys between 2010 and 2018. METHODS: Using a potential outcomes framework and the product method, we decomposed the total effect linking wealth and recent (<12 months) HIV testing into direct effects, and indirect effects, via internal (related to individual's ability to perceive need for and to seek care) or external (ability to reach, pay for and engage in healthcare) mediators to calculate the proportion mediated (PM) by each mediator. RESULTS: High levels of inequalities were observed in nine and 15 countries among women and men, respectively. The mediator indirect effect varied greatly across countries. The PM tended to be higher for internal than for external mediators. For instance, among women, HIV-related knowledge was estimated to mediate up to 12.1% of inequalities in Côte d'Ivoire; and up to 31.5% for positive attitudes towards people with HIV (PWH) in Senegal. For the four external mediators, the PM was systematically below 7%. Similar findings were found when repeating analyses on men for the internal mediators, with higher PM by attitudes towards PWH (up to 39.9% in Senegal). CONCLUSIONS: Our findings suggest that wealth-related inequalities in HIV testing may be mediated by internal more than external characteristics, with important variability across countries. Overall, the important heterogeneities in the pathways of wealth-related inequalities in HIV testing illustrate that addressing inequalities requires tailored efforts and upstream interventions.

"Co-construction" in deliberative democracy: lessons from the French Citizens' Convention for Climate.

Launched in 2019, the French Citizens' Convention for Climate (CCC) tasked 150 randomly chosen citizens with proposing fair and effective measures to fight climate change. This was to be fulfilled through an "innovative co-construction procedure", involving some unspecified external input alongside that from the citizens. Did inputs from the steering bodies undermine the citizens' accountability for the output? Did co-construction help the output resonate with the general public, as is expected from a citizens' assembly? To answer these questions, we build on our unique experience in observing the CCC proceedings and documenting them with qualitative and quantitative data. We find that the steering bodies' input, albeit significant, did not impair the citizens' agency, creativity, and freedom of choice. While succeeding in creating consensus among the citizens who were involved, this co-constructive approach, however, failed to generate significant support among the broader public. These results call for a strengthening of the commitment structure that determines how follow-up on the proposals from a citizens' assembly should be conducted.

The effects of Uber diffusion on the mental health of drivers.

While the spread of digital technologies and the growth of associated atypical forms of work are attracting increasing attention, little is known about the impact of these new forms of work on psychological well-being. This paper examines the effect of Uber diffusion on the mental health of drivers, taking advantage of the rollout of Uber across UK regions. We match individual-level information on health and sociodemographic characteristics from the UK Household Longitudinal Study (Understanding Society) between 2009 and 2019 with data on the diffusion of Uber across the country. We first show that Uber diffusion is positively associated with mental health, as measured by the General Health Questionnaire, in the population group of self-employed drivers. We argue that this positive correlation captures a selection effect (of comparatively healthier individuals into the category of self-employed drivers after Uber entry) and the omission of unobserved factors, rather than a causal effect. Indeed, we do not observe any improvement in mental health for workers who were already self-employed drivers before Uber entry. In parallel with this, among individuals who remained salaried drivers over time, our results suggest there may be a decline in mental health after Uber's introduction, probably because they feel the competition from Uber drivers.

Gig Workers during the COVID-19 Crisis in France: Financial Precarity and Mental Well-Being.

We set out to explore how precarious workers, particularly those employed in the gig economy, balance financial uncertainty, health risks, and mental well-being. We surveyed and interviewed precarious workers in France during the COVID-19 crisis, in March and April 2020. We oversampled gig economy workers, in particular in driving and food delivery occupations (hereafter drivers and bikers), residing in metropolitan areas. These workers cannot rely on stable incomes and are excluded from the labor protections offered to employees, features which have been exacerbated by the crisis. We analyzed outcomes for precarious workers during the mandatory lockdown in France as an extreme case to better understand how financial precarity relates to health risks and mental well-being. Our analysis revealed that 3 weeks into the lockdown, 56% of our overall sample had stopped working and respondents had experienced a 28% income drop on average. Gig economy drivers reported a significant 20 percentage point larger income decrease than other workers in our sample. Bikers were significantly more likely to have continued working outside the home during the lockdown. Yet our quantitative analysis also revealed that stress and anxiety levels were not higher for these groups and that bikers in fact reported significantly lower stress levels during the lockdown. While this positive association between being a biker and mental health may be interpreted in different ways, our qualitative data led to a nuanced understanding of the effect of gig work on mental well-being in this population group.

Retirement and Unexpected Health Shocks.

Is retirement good for your health? We complement previous studies by exploring the effect of retirement on unexpected health evolution. Using panel data from the Household, Income and Labour Dynamics in Australia survey (2001-2014), we construct measures of the mismatch between individual expected and actual health evolution (hereafter "health shocks"). In our approach, reverse causation running from health shocks to retirement is highly unlikely, because we look at shocks that happen after retirement, and those shocks are, by definition, unanticipated. We find that retirement decreases the probability of negative shocks (by approximately 16% to 24% for men and 14% to 23% for women) while increasing the likelihood of positive shocks (by 9% to 14% for men and 10% to 13% for women). This result is robust to the use of different lead-lag structures and of alternative measures of health change. Our findings are thus consistent with a positive impact of retirement on health.

The impact of institution use on the wellbeing of Alzheimer's disease patients and their caregivers.

In France, temporary institutionalization solutions for dependent elders have been encouraged since the early 2000s. They are targeting patients who are maintained at home, but may need temporary solutions to adjust the constraints of caregivers, e.g. to facilitate transitions between several informal care providers or to allow informal caregivers to leave for holidays. However, the influence of these solutions on dependent elders and their caregivers has not been explored yet. We use French longitudinal data (REAL.FR, 686 elders and their primary caregivers followed between 2000 and 2006) to explore the impact of institution placement on the wellbeing of both Alzheimer's disease patients and their primary informal caregivers. The data distinguishes permanent placements in institution from temporary stays. Using fixed-effect models, we quantify the change in patients' quality of life and caregivers' burden of care following the placement of patients. We find that permanent and temporary stays are associated with a decrease in informal caregivers' burden. However, only permanent stays lead to an improvement of patients' quality of life. Hence, taken together, the results suggest that while long-run placements may maximize the wellbeing of all the members of a household (patient and caregiver), this is not necessarily the case of short-term placements.

Parents' education and child body weight in France: The trajectory of the gradient in the early years.

This paper explores the relationship between parental education and offspring body weight in France. Using two large datasets spanning the 1991-2010 period, we examine the existence of inequalities in maternal and paternal education and reported child body weight measures, as well as their evolution across childhood. Our empirical specification is flexible and allows this evolution to be non-monotonic. Significant inequalities are observed for both parents' education--maternal (respectively paternal) high education is associated with a 7.20 (resp. 7.10) percentage points decrease in the probability that the child is reported to be overweight or obese, on average for children of all ages. The gradient with respect to parents' education follows an inverted U-shape across childhood, meaning that the association between parental education and child body weight widens from birth to age 8, and narrows afterward. Specifically, maternal high education is correlated with a 5.30 percentage points decrease in the probability that the child is reported to be overweight or obese at age 2, but a 9.62 percentage points decrease at age 8, and a 1.25 percentage point decrease at age 17. The figures for paternal high education are respectively 5.87, 9.11, and 4.52. This pattern seems robust, since it is found in the two datasets, when alternative variables for parental education and reported child body weight are employed, and when controls for potential confounding factors are included. The findings for the trajectory of the income gradient corroborate those of the education gradient. The results may be explained by an equalization in actual body weight across socioeconomic groups during youth, or by changes in reporting styles of height and weight.

Winning big but feeling no better? The effect of lottery prizes on physical and mental health.

We use British panel data to determine the exogenous impact of income on a number of individual health outcomes: general health status, mental health, physical health problems, and health behaviours (drinking and smoking). Lottery winnings allow us to make causal statements regarding the effect of income on health, as the amount won by winners is largely exogenous. Positive income shocks have no significant effect on self-assessed overall health, but a significant positive effect on mental health. This result seems paradoxical on two levels. First, there is a well-known gradient in health status in cross-sectional data, and second, general health should partly reflect mental health, so that we may expect both variables to move in the same direction. We propose a solution to the first apparent paradox by underlining the endogeneity of income. For the second, we show that lottery winnings are also associated with more smoking and social drinking. General health will reflect both mental health and the effect of these behaviours and so may not improve following a positive income shock.

Social interactions and malaria preventive behaviors in sub-saharan Africa.

This paper examines the existence of social interactions in malaria preventive behaviors in Sub-Saharan Africa, that is, whether an individual's social environment has an influence on the individual's preventive behaviors. We focus on the two population groups which are the most vulnerable to malaria (children under 5 years and pregnant women) and on two preventive behaviors (sleeping under a bednet and taking intermittent preventive treatment during pregnancy). We define the social environment of the individual as people living in the same region. To detect social interactions, we calculate the size of the social multiplier by comparing the effects of an exogenous variable at individual and regional levels. Our data come from 92 surveys for 29 Sub-Saharan countries between 1999 and 2012, and they cover approximately 660,000 children and 95,000 women. Our results indicate that there are social interactions in malaria preventive behaviors in the form of social multipliers effects of women's education and household wealth. The long-run effects of these characteristics on preventive behaviors at the regional level are larger than those apparent at the individual level.

Health policies and the relationships between socioeconomic status, access to health care, and health.

Health policies tend to focus on improving the access to health care of persons of low-socioeconomic status to improve their health. This commentary argues that health policies directly directed at health and socioeconomic status (and other components of individual welfare) will also be effective if one wants to improve the well-being of the poor.

Family income and child health in the UK.

Recent studies examining the relationship between family income and child health in the UK have produced mixed findings. We re-examine the income gradient in child general health and its evolution with child age in this country, using a very large sample of British children. We find that there is no correlation between income and child general health at ages 0-1, that the gradient emerges around age 2 and is constant from age 2 to age 17. In addition, we show that the gradient remains large and significant when we reduce the endogeneity of income. Furthermore, our results indicate that the gradient in general health reflects a greater prevalence of chronic conditions among low-income children and a greater severity of these conditions. Taken together, these findings suggest that income does matter for child health in the UK and may play a role in the intergenerational transmission of socioeconomic status.

Measuring health polarization with self-assessed health data.

This paper proposes an axiomatic foundation for new measures of polarization that can be applied to ordinal distributions such as self-assessed health (SAH) data. This is an improvement over the existing measures of polarization that can be used only for cardinal variables. The new measures of polarization avoid one difficulty that the related measures for evaluating health inequalities face. Indeed, inequality measures are mean based, and since only cardinal variables have a mean, SAH has to be cardinalized to compute a mean, which can then be used to calculate an inequality measure. In contrast, the new polarization measures are median based and hence do not require to impose cardinal scaling on the categories. After deriving the properties of these new polarization measures, we provide an empirical illustration using data from the British Household Panel Survey that demonstrates that SAH polarization is also a relevant question on empirical grounds, and that the polarization measures are adequate to evaluate polarization phenomena whereas inequality measures are not adequate in these cases.