Trends and structural factors affecting health equity in the United States at the local level, 1990-2019.

Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

Longitudinal trajectories of suicidal ideation among child welfare-involved 7- to 12-year-old children.

BACKGROUND: Young children involved in the child welfare system (CWS) are at high risk for suicidal ideation (SI) at a time when overall rates of suicide death in this age group are rising. Yet risk factors for and changes in SI over time are poorly understood in this population. METHOD: We combined data from two large representative longitudinal studies of children involved in the United States CWS. We examined patterns of SI among children who were between ages 7 and 12 years at the initial survey wave (N = 2,186), assessed at three waves using a measure of SI in the past 2 weeks. We conducted a multinomial regression to understand the baseline demographic, child maltreatment, and mental health characteristics that distinguish the trajectories. RESULTS: There were eight different subgroups (Non-Ideators, Late Ideators, Boomerang Ideators, Delayed Ideators, Desisters, Boomerang Non-Ideators, Late Desisters, and Persisters). Differences in race, type of maltreatment, sex, and mental health symptoms were identified when comparing Persisters (SI at all three waves) to other groups. CONCLUSIONS: These findings can help researchers and practitioners to develop strategies for better identifying CWS-involved children who are in greatest need of suicide risk monitoring and intervention.

Structural Racism and Well-Being Among Young People in the U.S.

INTRODUCTION: Structural racism has clear and pernicious effects on population health. However, there is a limited understanding of how structural racism impacts young people's well-being. The objective of this ecologic cross-sectional study was to assess the relationship between structural racism and well-being for 2,009 U.S. counties from 2010 to 2019. METHODS: Population-based data on demographics, health, and other variables related to young people's ability to thrive are used to construct a previously validated composite index that serves as a proxy of young people's well-being. The index is regressed on several forms of structural racism (segregation, economic, and educational) both independently and jointly while accounting for county-fixed effects, time trends, and state-specific trends as well as weighting for child population. Data were analyzed from November 2021 through March 2023. RESULTS: Higher levels of structural racism are associated with lower well-being. A 1-SD increase in Black-White child poverty disparity is associated with a -0.034 (95% CI= -0.019, -0.050) SD change in index score. When accounting for multiple structural racism measures, associations remain statistically significant. In joint models, only estimates for economic racism measures remain significant when additionally controlling for demographic, socioeconomic, and adult health measures (ß= -0.015; 95% CI= -0.001, -0.029). These negative associations are heavily concentrated in counties where Black and Latinx children are overrepresented. CONCLUSIONS: Structural racism-particularly of the kind that produces racialized poverty outcomes-has a meaningful adverse association with child and adolescent well-being, which may produce lifelong effects. Studies of structural racism among adults should consider a lifecourse perspective.

Dashboards as Mechanisms for Community Empowerment: Developing a Prototype for Child and Adolescent Well-being in California.

CONTEXT: In recent years, stakeholders in public health have emphasized measuring young peoples' well-being as a more holistic and upstream approach to understanding their health and development. However, summarizing the available indicators of well-being in ways that strengthen ongoing policy and community efforts remains a challenge. PROGRAM: Our objective was to develop a measurement framework of young peoples' well-being that would be engaging and actionable to a broad and diverse set of stakeholders in California. IMPLEMENTATION: We began with a scan of the relevant literature documenting previous efforts to measure young peoples' well-being, both within the United States and internationally. Subsequently, we individually interviewed a set of key informants and then convened a multidisciplinary panel of experts to solicit feedback on our approach. Throughout this iterative and collaborative process, we developed and refined a measurement framework based on the information provided across these various sources. EVALUATION: Findings suggest data dashboards are a promising approach for presenting a parsimonious yet holistic picture of young peoples' well-being. Dashboards can highlight well-being's multidimensionality by categorizing indicators over different domains. Our framework organizes indicators over 5 types: child-centric, subjective well-being, contextual determinants, developmental, and equity-focused. The design and flexibility of dashboards can also highlight important gaps in data collection that are of interest to end users such as indicators not yet collected among the broader population. Furthermore, dashboards can include interactive features, such as selecting key data elements, that can help communities articulate priority areas for policy action, thereby generating momentum and enthusiasm for future iterations and improvements. DISCUSSION: Data dashboards are well suited for engaging a variety of stakeholders on complex multidimensional concepts such as young peoples' well-being. However, to fulfill their promise, they should be codesigned and codeveloped through an iterative process with the stakeholders and community members they intend to serve.

Mixed Signals in Child and Adolescent Mental Health and Well-Being Indicators in the United States: A Call for Improvements to Population Health Monitoring.

Policy Points Social indicators of young peoples' conditions and circumstances, such as high school graduation, food insecurity, and smoking, are improving even as subjective indicators of mental health and well-being have been worsening. This divergence suggests policies targeting the social indicators may not have improved overall mental health and well-being. There are several plausible reasons for this seeming contradiction. Available data suggest the culpability of one or several common exposures poorly captured by existing social indicators. Resolving this disconnect requires significant investments in population-level data systems to support a more holistic, child-centric, and up-to-date understanding of young people's lives.

Trends in Measures of Child and Adolescent Well-being in the US From 2000 to 2019.

Importance: Improving child and adolescent well-being is a critical public health goal, yet monitoring of this measure at the national level remains limited. Composite indices aggregate existing indicators from population data sources, but these indices currently have weaknesses that may inhibit widespread use. Objective: To apply a novel, more child-centric index method to document changes in overall child and adolescent well-being in the US from 2000 to 2019, assess which states and racial and ethnic subpopulations experienced the greatest inequities in well-being, and identify the specific components associated with changes in the index over time. Design, Setting, and Participants: This cross-sectional study applied the Child and Adolescent Thriving Index 1.0 to population-level data from 2000 to 2019 from several data sources. The area-based sampling frame for each of the component data sources allowed for nationally representative estimates for every year of the study period. The indices for every state and by race and ethnicity were also calculated. Due to the scope and breadth of the index components from across the life course, the Child and Adolescent Thriving Index 1.0 is intended to approximate the well-being of persons up to age 17 years. Data were analyzed from June 7, 2021, to March 17, 2022. Exposures: Time in years. Main Outcomes and Measures: The Child and Adolescent Thriving Index 1.0 is a weighted mean of 11 indicators intended to proxy well-being. The index comprises 11 components: non-low birth weight in neonates, preschool attendance in children aged 3 to 4 years, reading proficiency in fourth-grade students, math proficiency in eighth-grade students, food security in children younger than 18 years, general health status, nonobesity in high school students, nonsmoking in adolescents aged 12 to 17 years, non-marijuana use in adolescents aged 12 to 17 years, high school graduation in young adults aged 18 to 21 years, and nonarrest rate in children aged 10 to 17 years. The index ranges from 0 to 1, with 0 indicating minimum and 1 indicating maximum possible well-being at the population level. Results: The Child and Adolescent Thriving Index 1.0 was applied to data from 12 320 national, state, and racial and ethnic population-level estimates. Over the study period, the Child and Adolescent Thriving Index 1.0 score increased from 0.780 points in 2000 to 0.843 points in 2019. Despite some convergence in geographic and racial and ethnic disparities, inequities were still present in 2019 in the South (-0.021 points) compared with the Northeast and among American Indian or Alaska Native (-0.079 points), Black (-0.053 points), and Latinx (-0.047 points) children and adolescents compared with White youths. Index components most associated with the overall increases in index scores of well-being were high school graduation rate (+0.028 units) and nonsmoking in adolescents (+0.022 units), amounting to 80.6% of the total increase. Conclusions and Relevance: Results of this study suggest that child and adolescent well-being scores increased from 2000 to 2019, but substantial work remains to address persistent inequities across states and racial and ethnic populations. The newly developed Child and Adolescent Thriving Index 1.0 may be used in future work to evaluate which public policy types (economic, social, health care, housing, or education) are associated with higher levels of well-being.

The Child and Adolescent Thriving Index 1.0: Developing a Measure of the Outcome Indicators of Well-Being for Population Health Assessment.

The well-being of children and adolescents is emerging as an area of interest for population health measurement. Previous approaches assessing national and state trends in well-being have relied on composite indices. However, these methodologies suffer from several weaknesses. This paper develops an improved index for the United States that is measurable with existing population-data resources. It derives the appropriate weights for items in this index using a longitudinal panel of 2,942 children in the Panel Study of Income Dynamics. Candidate component measures are selected for the index based on their demonstrated association with several subjective scales assessed during young adulthood. The final index demonstrates that a broad range of measures indicate higher levels of population-level well-being. The predictive validity of the index for outcomes during young adulthood is also assessed: a one-standard-deviation increase in the index score is associated with a 7.9-percentage-point decrease [95% CI: 5.9 - 9.8] in ever reporting fair or poor health, a 6.3-percentage-point decrease [95% CI: 4.6 - 8.0] in ever reporting depression, and a 17.2% [95% CI: 13.7% - 20.5%] increase in peak earnings. These values for predictive validity are slightly higher than those of existing methodologies. We also find that incorporating contextual indicators from childhood and adolescence does not substantively improve predictive validity. Policy-makers and government agencies interested in population-level well-being of children and adolescents can continue to use existing indices as reasonable proxies, but should also commit to upgrading data systems to make them more child-centric in the future. Supplementary Information: The online version contains supplementary material available at 10.1007/s12187-022-09962-0.

Trends in health equity in mortality in the United States, 1969-2019.

RATIONALE: Health equity is a significant concern of public health, yet a comprehensive assessment of health equity in the United States over time is lacking. While one might presume that overall health will improve with rising living standards, no such presumption is warranted for health equity, which may decline even as average health improves. OBJECTIVES: To assess trends in national and state-level health equity in mortality for people up to age 25, ages 25-64 and aged 65 and older. METHODS: A health equity metric was calculated as the weighted mean life expectancy relative to a benchmark level, defined as the life expectancy of the most socially-privileged subpopulation (white, non-Latinx males with a college education or higher).We analyzed 114,558,346 death records from the National Center for Health Statistics, from January 1, 1969 to December 31, 2019 to estimate health equity annually at the national and state-level. Using ICD-9/ICD-10 classification codes, inequities in health were decomposed by major causes of death. RESULTS: From 1969 to 2019, health equity in the United States improved (+0.36 points annually [95% CI 0.31-0.41]), albeit at a slower rate over the last two decades (+0.08 points annually [95% CI 0.03-0.14] from 2000 to 2019, compared to +0.57 points annually from 1969 to 2000 [95% CI 0.50-0.65]). Health equity among those under 25 improved substantially (+0.82 points annually [95% CI 0.75-0.89]) but remained flat for adults 25-64 (-0.01 points annually [95% CI -0.03-0.003]) For those over 65, health equity displayed a downward trend (-0.08 points annually [95% CI -0.09 to -0.07]). Gains in equity from reduced unintentional injuries and homicides have been largely offset by rising mortality attributable to drug overdoses. CONCLUSIONS: The US is failing to advance health equity, especially for adults. Keeping policy-makers accountable to a summary measure of health equity may help coordinate efforts at improving population health.

Trends in Health Equity Among Children in the United States, 1997-2018.

OBJECTIVES: Health equity is crucial to population health. To achieve this aim, extensive monitoring efforts beyond traditional disparities research are required. This analysis assesses trends in health equity for children from 1997 to 2018. METHODS: Health equity in a given year is calculated using a previously developed measure as the mean weighted departure of individual health from the best achievable level of health. This criterion is defined as the median health of the most socially privileged identifiable group: white, non-Latinx boys in upper-income households. Using more than 20 years of data from the National Health Interview Survey, we apply this methodology to six measures of child health: parent-reported health status, school days missed due to illness or injury in the past year, a strength and difficulties questionnaire score, emotional difficulties, a toddler mental health indicator score, and toddler depression. We separately calculate racial/ethnic and income disparities. Monte Carlo simulation is used to assess whether trends are statistically significant. RESULTS: Health equity among children increased gradually over the past 2 decades, with five of the six measures demonstrating upward trends. Improvements in health equity are stronger among younger children (age 0-3 and 4-7). Unlike previous work examining adults, both types of disparities narrowed over the study period. CONCLUSIONS FOR PRACTICE: Progress on health equity requires accountability to an objective metric. This analysis suggests some improvement over the past two decades, although these gains are under threat from potential decreases in government spending on programs affecting children and the COVID-19 pandemic.

Optimal uses of pooled testing for COVID-19 incorporating imperfect test performance and pool dilution effect: An application to congregate settings in Los Angeles County.

INTRODUCTION: Pooled testing is a potentially efficient alternative strategy for COVID-19 testing in congregate settings. We evaluated the utility and cost-savings of pooled testing based on imperfect test performance and potential dilution effect due to pooling and created a practical calculator for online use. METHODS: We developed a 2-stage pooled testing model accounting for dilution. The model was applied to hypothetical scenarios of 100 specimens collected during a one-week time-horizon cycle for varying levels of COVID-19 prevalence and test sensitivity and specificity, and to 338 skilled nursing facilities (SNFs) in Los Angeles County (Los Angeles) (data collected and analyzed in 2020). RESULTS: Optimal pool sizes ranged from 1 to 12 in instances where there is a least one case in the batch of specimens. 40% of Los Angeles SNFs had more than one case triggering a response-testing strategy. The median number (minimum; maximum) of tests performed per facility were 56 (14; 356) for a pool size of 4, 64 (13; 429) for a pool size of 10, and 52 (11; 352) for an optimal pool size strategy among response-testing facilities. The median costs of tests in response-testing facilities were $8250 ($1100; $46,100), $6000 ($1340; $37,700), $6820 ($1260; $43,540), and $5960 ($1100; $37,380) when adopting individual testing, a pooled testing strategy using pool sizes of 4, 10, and optimal pool size, respectively. CONCLUSIONS: Pooled testing is an efficient strategy for congregate settings with a low prevalence of COVID-19. Dilution as a result of pooling can lead to erroneous false-negative results.

Association of the Timing of School Closings and Behavioral Changes With the Evolution of the Coronavirus Disease 2019 Pandemic in the US.

Importance: The consequences of school closures for children's health are profound, but existing evidence on their effectiveness in limiting severe acute respiratory syndrome coronavirus 2 transmission is unsettled. Objective: To determine the independent associations of voluntary behavioral change, school closures, and bans on large gatherings with the incidence and mortality due to coronavirus disease 2019 (COVID-19). Design, Setting, and Participants: This population-based, interrupted-time-series analysis of lagged independent variables used publicly available observational data from US states during a 60-day period from March 8 to May 18, 2020. The behavioral measures were collected from anonymized cell phone or internet data for individuals in the US and compared with a baseline of January 3 to February 6, 2020. Estimates were also controlled for several state-level characteristics. Exposures: Days since school closure, days since a ban on gatherings of 10 or more people, and days since residents voluntarily conducted a 15% or more decline in time spent at work via Google Mobility data. Main Outcomes and Measures: The natural log of 7-day mean COVID-19 incidence and mortality. Results: During the study period, the rate of restaurant dining declined from 1 year earlier by a mean (SD) of 98.3% (5.2%) during the study period. Time at work declined by a mean (SD) of 40.0% (7.9%); time at home increased by a mean (SD) of 15.4% (3.7%). In fully adjusted models, an advance of 1 day in implementing mandatory school closures was associated with a 3.5% reduction (incidence rate ratio [IRR], 0.965; 95% CI, 0.946-0.984) in incidence, whereas each day earlier that behavioral change occurred was associated with a 9.3% reduction (IRR, 0.907; 95% CI, 0.890-0.925) in incidence. For mortality, each day earlier that school closures occurred was associated with a subsequent 3.8% reduction (IRR, 0.962; 95% CI, 0.926-0.998), and each day of advance in behavioral change was associated with a 9.8% reduction (IRR, 0.902; 95% CI, 0.869-0.936). Simulations suggest that a 2-week delay in school closures alone would have been associated with an additional 23 000 (95% CI, 2000-62 000) deaths, whereas a 2-week delay in voluntary behavioral change with school closures remaining the same would have been associated with an additional 140 000 (95% CI, 65 000-294 000) deaths. Conclusions and Relevance: In light of the harm to children of closing schools, these findings suggest that policy makers should consider better leveraging the public's willingness to protect itself through voluntary behavioral change.

Trends in Health Equity in the United States by Race/Ethnicity, Sex, and Income, 1993-2017.

Importance: Health equity is an often-cited goal of public health, included among the 4 overarching goals of the Department of Health and Human Services' Healthy People 2020. Yet it is difficult to find summary assessments of national progress toward this goal. Objectives: To identify variation in several measures of health equity from 1993 to 2017 in the United States and to test whether there are significant time trends. Design, Setting, and Participants: Survey study using 25 years of data, from January 1, 1993, to December 31, 2017, from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System to assess trends in health equity and health justice by race/ethnicity, sex, and income in 3 categories by year. Main Outcomes and Measures: Health equity was assessed separately for each of 2 health constructs: healthy days-the average of physical and mental healthy days over the previous 30 days-and general health in 5 categories, rescaled to approximate a continuous variable. For each health construct, average health was calculated along with 4 measures of health equity: disparities across 3 income groups; black-white disparities; health justice-a measure of the correlation of health outcomes with income, race/ethnicity and sex; and a summary health equity metric. Results: Among the 5 456 006 respondents, the mean (SD) age was 44.5 (12.7) years; 3 178 688 (58.3%) were female; 4 163 945 (76.3%) were non-Latinx white; 474 855 (8.7%) were non-Latinx black; 419 542 (7.7%) were Latinx; and 397 664 (7.3%) were of other race/ethnicity. The final sample included 5 456 006 respondents for self-reported health and 5 349 527 respondents for healthy days. During the 25-year period, the black-white gap showed significant improvement (year coefficient: healthy days, 0.021; 97.5% CI, 0.012 to 0.029; P < .001; self-reported health, 0.030; 97.5% CI, 0.025 to 0.035; P < .001). The health equity metric for self-reported health showed no significant trend. For healthy days, the Health Equity Metric declined over time (year coefficient: healthy days, -0.025; 97.5% CI, -0.033 to -0.017; P < .001). Health justice declined over time (year coefficient: healthy days, -0.045; 97.5% CI, -0.053 to -0.038; P < .001; self-reported health, -0.035; 97.5% CI, -0.046 to-0.023; P < .001), and income disparities worsened (year coefficient: healthy days, -0.060; 97.5% CI, -0.076 to -0.044; P < .001; self-reported health, -0.029; 97.5% CI, -0.046 to -0.012; P < .001). Conclusions and Relevance: Results of this analysis suggest that there has been a clear lack of progress on health equity during the past 25 years in the United States. Achieving widely shared goals of improving health equity will require greater effort from public health policy makers, along with their partners in medicine and the sectors that contribute to the social determinants of health.