Improving population health by reducing poverty: New York's Earned Income Tax Credit.

Despite the established relationship between adverse health outcomes and low socioeconomic status, researchers rarely test the link between health improvements and poverty-alleviating economic policies. New research, however, links individual-level health improvements to the Earned Income Tax Credit (EITC), a broad-based income support policy. We build on these findings by examining whether the EITC has ecological, neighborhood-level health effects. We use a difference-in-difference analysis to measure child health outcomes in 90 low- and middle- income neighborhoods before and after the expansion of New York State and New York City's EITC policy between 1997-2010. Our study takes advantage of the relatively exogenous source of income variation supplied by the EITC-legislative changes to EITC policy parameters. This feature minimizes the endogeneity problem in studying the relationship between income and health. Our estimates link a 15-percentage-point increase in EITC benefit rates to a 0.45 percentage-point reduction in the low birthweight rate. We do not observe any measurable link between EITC benefits and prenatal health or asthma-related pediatric hospitalization. The magnitude of the EITC's impact on low birthweight rates suggests ecological effects, and an additional channel through which anti-poverty measures can serve as public health interventions.

Integrating Social Determinants of Health With Treatment and Prevention: A New Tool to Assess Local Area Deprivation.

We assessed the appropriate geographic scale to apply an area deprivation index (ADI), which reflects a geographic area's level of socioeconomic deprivation and is associated with health outcomes, to identify and screen patients for social determinants of health. We estimated the relative strength of the association between the ADI at various geographic levels and a range of hospitalization rates by using age-adjusted odds ratios in an 8-county region of New York State. The 10-km local ADI estimates had the strongest associations with all hospitalization rates (higher odds ratios) followed by estimates at 20 km, 30 km, and the regional scale. A locally sensitive ADI is an ideal measure to identify and screen for the health care and social services needs and to advance the integration of social determinants of health with clinical treatment and disease prevention.

Overweight and obesity: can we reconcile evidence about supermarkets and fast food retailers for public health policy?

The aim of this study is to determine whether access to fast food outlets and supermarkets is associated with overweight and obesity in New York City neighborhoods. We use a Bayesian ecologic approach for spatial prediction. Consistent with prior research, we find no association between fast food density and overweight or obesity. Consistent with prior research, we find that supermarket access has a salutary impact on overweight and obesity. Given the lack of empirical evidence linking fast food retailers with adverse health outcomes, policymakers should be encouraged to adopt policies that incentivize the establishment of supermarkets and the modification of existing food store markets and retailers to offer healthier choices. Reaching within neighborhoods and modifying the physical environment and public health prevention and intervention efforts based on the characteristics of those neighborhoods may play a key role in creating healthier communities.

Social security and mortality: the role of income support policies and population health in the United States.

Social Security is the most important and effective income support program ever introduced in the United States, alleviating the burden of poverty for millions of elderly Americans. We explored the possible role of Social Security in reducing mortality among the elderly. In support of this hypothesis, we found that declines in mortality among the elderly exceeded those among younger age groups following the initial implementation of Social Security in 1940, and also in the periods following marked improvements in Social Security benefits via legislation and indexing of benefits that occurred between the mid-1960s and the early 1970s. A better understanding of the link between Social Security and health status among the elderly would add a significant and missing dimension to the public discourse over the future of Social Security, and the potential role of income support programs in reducing health-related socioeconomic disparities and improving population health.

Not Just a Walk in the Park: Methodological Improvements for Determining Environmental Justice Implications of Park Access in New York City for the Promotion of Physical Activity.

The purpose of this study is to test the hypothesis that access to parks in New York City is not equitable across racial and ethnic categories. It builds on previous research that has linked access to parks and open space with increased physical activity, which in turn may reduce the risk for adverse health outcomes related to obesity. Systematic patterns of uneven access to parks might help to explain disparities in these health outcomes across sociodemographic populations that are not fully explained by individual-level risk factors and health behaviors, and therefore access to parks becomes an environmental justice issue. This study is designed to shed light on the "unpatterned inequities" of park distributions identified in previous studies of New York City park access. It uses a combination of network analysis and a cadastral-based expert dasymetric system (CEDS) to estimate the racial/ethnic composition of populations within a reasonable walking distance of 400m from parks. The distance to the closest park, number of parks within walking distance, amount of accessible park space, and number of physical activity sites are then evaluated across racial/ethnic categories, and are compared to the citywide populations using odds ratios. The odds ratios revealed patterns that at first glance appear to contradict the notion of distributional inequities. However, discussion of the results points to the need for reassessing what is meant by "access" to more thoroughly consider the aspects of parks that are most likely to contribute to physical activity and positive health outcomes.

Bringing health and social policy together: the case of the earned income tax credit.

The principal objective of our research is to examine whether the earned income tax credit (EITC), a broad-based income support program that has been shown to increase employment and income among poor working families, also improves their health and access to care. A finding that the EITC has a positive impact on the health of the American public may help guide deliberations about its future at the federal, state, and local levels. The authors contend that a better understanding of the relationship between major socioeconomic policies such as the EITC and the public's health will inform the fields of health and social policy in the pursuit of improving population health.

The complexities of measuring access to parks and physical activity sites in New York City: a quantitative and qualitative approach.

BACKGROUND: Proximity to parks and physical activity sites has been linked to an increase in active behaviors, and positive impacts on health outcomes such as lower rates of cardiovascular disease, diabetes, and obesity. Since populations with a low socio-economic status as well as racial and ethnic minorities tend to experience worse health outcomes in the USA, access to parks and physical activity sites may be an environmental justice issue. Geographic Information systems were used to conduct quantitative and qualitative analyses of park accessibility in New York City, which included kernel density estimation, ordinary least squares (global) regression, geographically weighted (local) regression, and longitudinal case studies, consisting of field work and archival research. Accessibility was measured by both density of park acreage and density of physical activity sites. Independent variables included percent non-Hispanic black, percent Hispanic, percent below poverty, percent of adults without high school diploma, percent with limited English-speaking ability, and population density. RESULTS: The ordinary least squares linear regression found weak relationships in both the park acreage density and the physical activity site density models (R(a)(2) = .11 and .23, respectively; AIC = 7162 and 3529, respectively). Geographically weighted regression, however, suggested spatial non-stationary in both models, indicating disparities in accessibility that vary over space with respect to magnitude and directionality of the relationships (AIC = 2014 and -1241, respectively). The qualitative analysis supported the findings of the local regression, confirming that although there is a geographically inequitable distribution of park space and physical activity sites, it is not globally predicted by race, ethnicity, or socio-economic status. CONCLUSION: The combination of quantitative and qualitative analyses demonstrated the complexity of the issues around racial and ethnic disparities in park access. They revealed trends that may not have been otherwise detectable, such as the spatially inconsistent relationship between physical activity site density and socio-demographics. In order to establish a more stable global model, a number of additional factors, variables, and methods might be used to quantify park accessibility, such as network analysis of proximity, perception of accessibility and usability, and additional park quality characteristics. Accurate measurement of park accessibility can therefore be important in showing the links between opportunities for active behavior and beneficial health outcomes.

Cost-effectiveness analysis of integrated care for people with HIV, chronic mental illness and substance abuse disorders.

BACKGROUND: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers. AIMS OF THE STUDY: The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective. METHODS: Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS). RESULTS: During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study. IMPLICATIONS FOR HEALTH POLICIES: There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing. IMPLICATIONS FOR FURTHER RESEARCH: Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.

Triply-diagnosed patients in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: patterns of home care use.

Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.

Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders.

OBJECTIVE: To examine the effects of race/ethnicity, insurance, and type of substance abuse (SA) diagnosis on utilization of mental health (MH) and SA services among triply diagnosed adults with HIV/AIDS and co-occurring mental illness (MI) and SA disorders. DATA SOURCE: Baseline (2000 to 2002) data from the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. STUDY DESIGN: A multiyear cooperative agreement with 8 study sites in the United States. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered by trained interviewers to determine whether or not adults with HIV/AIDS had co-occurring MI and SA disorders. DATA COLLECTION/EXTRACTION METHODS: Subjects were interviewed in person about their personal characteristics and utilization of MH and SA services in the prior 3 months. Data on HIV viral load were abstracted from their medical records. PRINCIPAL FINDINGS: Only 33% of study participants received concurrent treatment for MI and SA, despite meeting diagnostic criteria for both: 26% received only MH services, 15% received only SA services, and 26% received no services. In multinomial logistic analysis, concurrent utilization of MH and SA services was significantly lower among nonwhite and Hispanic participants as a group and among those who were not dependent on drugs and alcohol. Concurrent utilization was significantly higher for people with Veterans Affairs Civilian Health and Medical Program of the Uniformed Services (VA CHAMPUS) insurance coverage. Two-part models were estimated for MH outpatient visits and 3 SA services: (1) outpatient, (2) residential, and (3) self-help groups. Binary logistic regression was estimated for any use of psychiatric drugs. Nonwhites and Hispanics as a group were less likely to use 3 of the 5 services; they were more likely to attend SA self-help groups. Participants with insurance were significantly more likely to receive psychiatric medications and residential SA treatment. Those with Medicaid were more likely to receive MH outpatient services. Participants who were alcohol dependent but not drug dependent were significantly less likely to receive SA services than those with dual alcohol and drug dependence. CONCLUSION: Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.

Income inequality and infant mortality in New York City.

A series of studies have demonstrated that people who live in regions where there are disparities in income have poorer average health status than people who live in more economically homogeneous regions. To test whether such disparities might explain health variations within urban areas, we examined the possible association between income inequality and infant mortality for zip code regions within New York City using data from the 1990 census and the New York City Department of Health. Both infant mortality and income inequality (percentage of income received by the poorest 50% of households) varied widely across these regions (range in infant mortality: 0.6-29.6/1,000 live births; range in income inequality: 12.7-27.3). An increase of one standard deviation in income inequality was associated with an increase of 0.80 deaths/1,000 live births (P <.001), controlling for other socioeconomic factors. This finding has important implications for public health practice and social epidemiological research in large urban areas, which face significant disparities both in health and in social and economic conditions.

Analysis of a population-based Pneumocystis carinii pneumonia index as an outcome measure of access and quality of care for the treatment of HIV disease.

OBJECTIVES: A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. METHODS: A zip code-level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). RESULTS: In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index =.05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village =.02532 vs Central Harlem =.08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island =.14035; northern Manhattan =.08756). CONCLUSIONS: The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery.

Breast-feeding promotion interventions: good public health and economic sense.

The health benefits of breast-feeding are well documented, as are the positive effects of breast-feeding promotion interventions. There is a clear dose-response relationship between breast-feeding and infant health in the first year of life, and beyond. Further, nearly all breast-feeding promotion interventions improve--at least minimally--breast-feeding initiation and duration rates. However, the extent to which the costs of such interventions might be offset by the potential health care cost savings during the infant's first year of life has not been examined. From a health policy perspective, such an economic analysis is indicated.