A global comparative study of wealth-pain gradients: Investigating individual- and country-level associations.

Pain is a significant yet underappreciated dimension of population health. Its associations with individual- and country-level wealth are not well characterized using global data. We estimate both individual- and country-level wealth inequalities in pain in 51 countries by combining data from the World Health Organization's World Health Survey with country-level contextual data. Our research concentrates on three questions: 1) Are inequalities in pain by individual-level wealth observed in countries worldwide? 2) Does country-level wealth also relate to pain prevalence? 3) Can variations in pain reporting also be explained by country-level contextual factors, such as income inequality? Analytical steps include logistic regressions conducted for separate countries, and multilevel models with random wealth slopes and resultant predicted probabilities using a dataset that pools information across countries. Findings show individual-level wealth negatively predicts pain almost universally, but the association strength differs across countries. Country-level contextual factors do not explain away these associations. Pain is generally less prevalent in wealthier countries, but the exact nature of the association between country-level wealth and pain depends on the moderating influence of country-level income inequality, measured by the Gini index. The lower the income inequality, the more likely it is that poor countries experience the highest and rich countries the lowest prevalence of pain. In contrast, the higher the income inequality, the more nonlinear the association between country-level wealth and pain reporting such that the highest prevalence is seen in highly nonegalitarian middle-income countries. Our findings help to characterize the global distribution of pain and pain inequalities, and to identify national-level factors that shape pain inequalities.

Longitudinal associations between mental health and social environment in older adults: a multilevel growth modeling.

OBJECTIVES: This study aimed to assess longitudinal relationships between social environment indicators (social connectedness, social engagement, social contribution) and mental health indicators (depression and anxiety) among community-dwelling adults age 55 years and older. METHODS: Data were drawn from 3-waves of the national longitudinal survey of Midlife Development in the United States (MIDUS) (N = 2,020; age range = 55-94 years). We developed multilevel growth models to ascertain the relationships of interest, controlling for sociodemographic and physical health factors. RESULTS: Over the 20-year period of study, lower levels of emotional social support, social integration and social contribution significantly predicted depression and anxiety, whereas social network and social engagement were not significant predictors of these mental health outcomes in older adults. The models also indicated a moderation effect of the number of chronic conditions on the slopes of depression and anxiety. DISCUSSION: Considering our findings, interventions to enhance social contribution and social connectedness could be effective to help older adults maintain positive mental health, as well as programs that facilitate older adults' connections with their families, communities and health care providers. These interventions must also account for multiple chronic conditions since functional limitations drive declining integration in the community and participation in social activities.

Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015.

OBJECTIVE: To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013. METHODS: In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders. RESULTS: Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served. CONCLUSION: Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.

Performance of an Abbreviated Lubben Social Network Scale (LSNS-6) in Three Ethnic Groups of Older Asian Americans.

BACKGROUND AND OBJECTIVES: The present study examined the measurement quality and performance of an abbreviated Lubben Social Network Scale (LSNS-6) in three ethnic groups (Chinese, Koreans, and Vietnamese) of older Asian Americans, addressing both within- and cross-group validations. RESEARCH DESIGN AND METHODS: We selected 605 participants aged 50 or older (242 Chinese, 150 Koreans, and 213 Vietnamese) from the 2015 Asian American Quality of Life survey, conducted with self-identified Asian Americans aged 18 or above living in central Texas. We analyzed LSNS-6 data on measurement qualities (internal consistency and corrected item-total correlation), dimensionality (exploratory and confirmatory factor analyses), and correlations with other indicators. RESULTS: LSNS-6 showed very good internal consistency in each ethnic group, and the two-factor structure of family and friends were invariant across the groups. The items on friends demonstrated greater homogeneity than those on family and emerged as a first factor. Both subscale and total scores of LSNS-6 were associated in expected directions with the social and health indicators considered. DISCUSSION AND IMPLICATIONS: The findings confirm the measurement qualities of LSNS-6 within each group and provide support for measurement invariance across the groups. While the observed difference in family and friend networks warrants further investigation, LSNS-6 serves as a viable option for the assessment of social networks. When using LSNS-6 with older Asian Americans, it is highly recommended to use the family/friend subscales in consideration of cultural and immigration contexts.

Living with a Smoker and Physical Inactivity across Eight Years in High-Risk Medical Patients.

Recent research has demonstrated a link between living with a smoker and physical inactivity. However, no research has examined this issue in the context of recovery in medical patients. The present study broadens research on living with a smoker by applying it to physical inactivity in a group of high-risk medical patients with histories of cancer or cardiovascular disease compared to a control group without histories of these conditions. In addition, this study extends the time frame of research on living with a smoker in predicting physical inactivity to eight years. Participants were 76,758 women between 49 and 81 years of age from the Women's Health Initiative Observational Study. Data on living with a smoker were collected at baseline; data on physical activity were collected at baseline and annually from 3 to 8 years. Analyses utilized latent growth modeling. Patient status, compared to control status, was associated with more physical inactivity at baseline. Independent of patient status, living with a smoker predicted a significant increase in the odds of no moderate or strenuous exercise and a significant increase in the odds of no walking at baseline. The effect of living with a smoker on physical inactivity was stronger than that of patient status. Moreover, the living with a smoker effect on physical inactivity remained stable across eight years. These findings highlight an overlooked impediment to compliance with recommendations for lifestyle change among high-risk medical patients.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception.

OBJECTIVE: To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program. STUDY DESIGN: In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type. RESULTS: Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use). CONCLUSIONS: In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods. IMPLICATIONS: State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.

Health Behaviors and Prenatal Health Conditions in Repeat Vs First-time Teenage Mothers in the United States: 2015-2018.

STUDY OBJECTIVE: Repeat teenage mothers, those who give birth to a second or higher-order infant before age 20 years, are at elevated risk for adverse perinatal outcomes compared with first-time teenage mothers. The objective of the current study was to compare the prevalence of negative pregnancy-related behaviors and gestational health conditions in the national United States population of first-time and repeat teenage mothers. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective, population-based cohort study using annual US birth data files from 2015 to 2018, N = 799,756 (673,394 [84.2%] first, 126,362 [15.8%] repeat) births to women ages 15-19 years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Pregnancy-related behaviors (including adequacy of prenatal care and weight gain, sexually transmitted infection, smoking, and breastfeeding) and gestational health conditions (gestational hypertension and gestational diabetes). RESULTS: Repeat (vs first-time) mothers had higher prevalence of negative pregnancy-related behaviors: inadequate prenatal care, smoking, inadequate weight gain, and sexually transmitted infection during pregnancy; they were also less likely to breastfeed. Conversely, repeat teenage mothers experienced lower prevalence of gestational hypertension and gestational diabetes. CONCLUSION: Repeat teenage mothers experienced lower prevalence of physical health complications during pregnancy but engaged in more negative pregnancy-related health behaviors. Negative health behavior in pregnancy can lead directly to poor perinatal outcomes for infants. To prevent adverse outcomes from repeat teenage childbearing, we must ensure access to quality, timely, prenatal and postpartum care so teenage mothers can receive support for healthy pregnancy-related behaviors as well as linkage to highly effective contraception to prevent unintended repeat births.

Living with a Smoker and Multiple Health-Risk Behaviors.

BACKGROUND: Behavioral medicine is showing growing theoretical and applied interest in multiple health-risk behaviors. Compared to engaging in a single health-risk behavior, multiple health-risk behaviors are linked to increased morbidity and mortality. A contextual determinant of multiple risk behaviors may be living with a smoker. PURPOSE: This study investigated the role of living with a smoker in predicting multiple health-risk behaviors compared to a single health-risk behavior, as well as whether these multiple risk behaviors occur across both physical activity and dietary domains. Moreover, the study tested these effects across 3 years in longitudinal and prospective (controlling for health-risk behaviors at baseline) analyses. METHODS: Participants were 82,644 women (age M = 63.5, standard deviation = 7.36, age range = 49-81) from the Women's Health Initiative Observational Study. Analyses used multinomial and binary logistic regression. RESULTS: Living with a smoker was more strongly associated with multiple health-risk behaviors than with a single health-risk behavior. These multiple risk behaviors occurred across both physical activity and dietary domains. The effects persisted across 3 years in longitudinal and prospective analyses. Living with a smoker, compared to not living with a smoker, increased the odds of multiple health-risk behaviors 82% cross-sectionally and, across 3 years, 94% longitudinally and 57% prospectively. CONCLUSIONS: These findings integrate research on multiple health-risk behaviors and on living with a smoker and underscore an unrecognized public health risk of tobacco smoking. These results are relevant to household-level interventions integrating smoking-prevention and obesity-prevention efforts.

Clarifying assumptions in age-period-cohort analyses and validating results.

BACKGROUND: Age-period-cohort (APC) models are often used to decompose health trends into period- and cohort-based sources, but their use in epidemiology and population sciences remains contentious. Central to the contention are researchers' failures to 1) clearly state their analytic assumptions and/or 2) thoroughly evaluate model results. These failures often produce varying conclusions across APC studies and generate confusion about APC methods. Consequently, scholarly exchanges about APC methods usually result in strong disagreements that rarely offer practical advice to users or readers of APC methods. METHODS: We use research guidelines to help practitioners of APC methods articulate their analytic assumptions and validate their results. To demonstrate the usefulness of the guidelines, we apply them to a 2015 American Journal of Epidemiology study about trends in black-white differences in U.S. heart disease mortality. RESULTS: The application of the guidelines highlights two important findings. On the one hand, some APC methods produce inconsistent results that are highly sensitive to researcher manipulation. On the other hand, other APC methods estimate results that are robust to researcher manipulation and consistent across APC models. CONCLUSIONS: The exercise shows the simplicity and effectiveness of the guidelines in resolving disagreements over APC results. The cautious use of APC models can generate results that are consistent across methods and robust to researcher manipulation. If followed, the guidelines can likely reduce the chance of publishing variable and conflicting results across APC studies.

Final Overall Survival Results from a Phase 3 Study to Compare Tivozanib to Sorafenib as Third- or Fourth-line Therapy in Subjects with Metastatic Renal Cell Carcinoma.

Tivozanib is a potent and selective inhibitor of the VEGF receptor. In an open-label, randomized phase 3 trial, we compared tivozanib to sorafenib in patients with metastatic renal cell carcinoma (mRCC) who had received two or three prior therapies. We have previously reported that the study met its primary endpoint, demonstrating an improvement in progression-free survival with tivozanib versus sorafenib (5.6 mo vs 3.9 mo; hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56-0.94; p=0.016). The current report reflects the final assessment of overall survival, showing no difference between treatment with tivozanib and sorafenib (HR 0.97, 95% CI 0.75-1.24). Given its activity and distinct tolerability profile, tivozanib represents a treatment option for patients with previously treated mRCC. PATIENT SUMMARY: We show that tivozanib, a targeted therapy, can delay tumor growth relative to an already approved targeted therapy (sorafenib) in patients with kidney cancer who have received two or three prior treatments. No difference in survival was observed.

A longitudinal evaluation of government-sponsored job skills training and basic employment services among U.S. baby boomers with economic disadvantages.

Job skills training is a cost-effective strategy for improving employment among individuals who have low income and employment barriers, but few U.S. government-sponsored employment program participants have received such training. To better understand long-term gains from job skills training, this study compared employment and earnings trajectories between program participants who received job skills training and those who received basic services only. Using data from the National Longitudinal Survey of Youth 1979, we estimated 33-year employment and earnings trajectories among U.S. baby-boomer cohorts while accounting for baseline group heterogeneity using inverse propensity score weighting. We found increases in employment rates over the life course, especially among Black women. Job skills training also increased earnings by up to 69.6 % compared to basic services only. Despite the long-term gains in employment and earnings, job skills training participation is not sufficient to address gender as well as racial and ethnic gaps in full-time employment. Findings reinforce the importance of incorporating job skills training as an essential service element of government-sponsored employment programs to improve long-term labor market outcomes among Americans with economic disadvantages.

Spillover Effects of Job Skills Training on Substance Misuse Among Low-Income Youths With Employment Barriers: A Longitudinal Cohort Study.

Objectives. To examine spillover effects of job skills training (vs basic services only [e.g., adult basic education, job readiness training]) on substance misuse among low-income youths with employment barriers.Methods. Data came from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of youths born between 1980 and 1984 in the United States. Based on respondents' reports of substance misuse (past-month binge drinking and past-year marijuana and other illicit drug use) from 2000 to 2016, we estimated substance misuse trajectories of job skills training (n = 317) and basic services (n = 264) groups. We accounted for potential selection bias by using inverse probability of treatment weighting.Results. Compared with the basic services group, the job skills training group showed notable long-term reductions in its illicit drug misuse trajectory, translating to a 56.9% decrease in prevalence rates from 6.5% in year 0 to 2.8% in year 16.Conclusions. Job skills training can be an important service component for reducing substance misuse and improving employment outcomes among youths with economic disadvantages and employment barriers.

Differences in abortion rates by race-ethnicity after implementation of a restrictive Texas law.

OBJECTIVE: To evaluate the association between a restrictive Texas law, House Bill 2 (HB2), and receipt of in-clinic abortion by patient's race-ethnicity. STUDY DESIGN: In this retrospective cohort study, we collected Texas state statistics on number of abortions, abortions per county, and abortions per county by race-ethnicity for 2012, before HB2 was enacted, and 2015, after HB2 was in effect. Using female reproductive-aged population estimates, we calculated the abortion rate and percent change in the abortion rate between the two time periods by county, patient residence in a county with an open clinic or HB2-related clinic closure, and change in distance to an open clinic for each race-ethnicity. We also used geospatial analyses to depict the greatest decrease in abortion rate by race-ethnicity and county. RESULTS: In Texas, there were 64,716 reported abortions in 2012 and 54,253 in 2015. Statewide, there was a 20% decrease in the abortion rate affecting all racial-ethnic groups, yet the reduction was greater among Hispanic women compared to White women (-25% vs. -16%, respectively). The abortion rate also decreased more among those living in a county with an HB2-related clinic closure, especially for Hispanic women (-41% Hispanic vs. -29% White vs. -30% Black vs. -3% Other). Hispanic women whose travel distance increased 100+ miles had the greatest reduction in the abortion rate (-43%). Geospatial mapping confirmed our quantitative findings. CONCLUSION: HB2 led to a disproportionate reduction in the abortion rate among Hispanic women in Texas, including those living in counties with a closed clinic or traveling long distances to obtain in-clinic abortion care. IMPLICATIONS: Restrictive abortion policies in Texas may disproportionately burden Hispanic women and those affected by clinic closures.

Breastfeeding Initiation, Duration, and Supplementation Among Mexican-Origin Women in Texas.

BACKGROUND: Mexican-origin women breastfeed at similar rates as white women in the United States, yet they usually breastfeed for less time. In our study, we seek to identify differences in Mexican-origin women's breastfeeding intentions, initiation, continuation, and supplementation across nativity and country-of-education groups. METHODS: The data are from a prospective cohort study of postpartum women ages 18 to 44 recruited from 8 Texas hospitals. We included 1235 Mexican-origin women who were born and educated in either Texas or Mexico. Women were interviewed at delivery and at 3, 6, 12, 18, and 24 months post partum. Breastfeeding intentions and initiation were reported at baseline, continuation was collected at each interview, and weeks until supplementation was assessed for both solids and formula. Women were classified into 3 categories: born and educated in Mexico, born and educated in the United States, and born in Mexico and educated in the United States. RESULTS: Breastfeeding initiation and continuation varied by nativity and country of birth, although all women reported similar breastfeeding intentions. Women born and educated in Mexico initiated and continued breastfeeding in higher proportions than women born and educated in the United States. Mexican-born and US-educated women formed an intermediate group. Early supplementation with formula and solid foods was similar across groups, and early supplementation with formula negatively impacted duration across all groups. CONCLUSIONS: Nativity and country of education are important predictors of breastfeeding and should be assessed in pediatric and postpartum settings to tailor breastfeeding support. Support is especially warranted among US-born women, and additional educational interventions should be developed to forestall early supplementation with formula across all acculturation groups.

The Effects of Family Transitions on Depressive Symptoms: Differences among Young Adults with and without Childhood Symptoms of Attention-Deficit/ Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is tied to higher levels of depression, but the social factors that shape these associations are not well understood. This study considers whether family transitions affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD at subthreshold or diagnostic levels. Between-within regression analysis of nationally representative longitudinal survey data shows that transitions into cohabitation and parenthood affect depressive symptoms differently for young adults with and without childhood symptoms of ADHD. Specifically, within-person effects indicate that transitions into cohabitation and parenthood are tied to decreases in depressive symptoms, but only for young adults without childhood symptoms of ADHD. In contrast, transitions into marriage are tied to decreases in depressive symptoms, and transitions out of coresidential unions are tied to increases in depressive symptoms, regardless of childhood symptoms of ADHD. The results suggest that some family transitions may work to widen ADHD disparities in depression, under-scoring the importance of family contexts for shaping mental health throughout the life course.

Race/ethnicity, maternal educational attainment, and infant mortality in the United States.

This study examines patterns of and explanations for racial/ethnic-education disparities in infant mortality in the United States. Using linked birth and death data (2007-2010), we find that while education-specific infant mortality rates are similar for Mexican Americans and Whites, infants of college-educated African American women experience 3.1 more deaths per 1,000 live births (Rate Ratio = 1.46) than infants of White women with a high school degree or less. The high mortality rates among infants born to African American women of all educational attainment levels are fully accounted for by shorter gestational lengths. Supplementary analyses of data from the National Longitudinal Study of Adolescent to Adult Health show that college-educated African American women exhibit similar socioeconomic, contextual, psychosocial, and health disadvantages as White women with a high school degree or less. Together, these results demonstrate African American-White infant mortality and socioeconomic, health, and contextual disparities within education levels, suggesting the role of life course socioeconomic disadvantage and stress processes in the poorer infant health outcomes of African Americans relative to Whites.

Living with a smoker, health risk behaviors, and adiposity: an analysis with middle-aged and older women.

This study investigated: (a) the association between living with a smoker and weight-related health risk behaviors, and (b) the role of these behaviors in indirectly linking living with a smoker to general and central adiposity. Participants were 83,492 women (age M = 63.5, SD = 7.36) from the Women's Health Initiative Observational Study. In logistic regression analyses at baseline, living with a smoker was associated with increased odds of no exercise (29%), no walking (33%), high dietary fat (62%), and low fruit and vegetable consumption (43%). Using structural equation modeling, bootstrap confidence intervals confirmed a significant indirect effect from living with a smoker to adiposity through health risk behaviors at baseline and prospectively across 3 and 8 years. Health risk behaviors fully explained the living with a smoker-adiposity relationship. These findings integrate clustering and contagion theoretical perspectives on health behaviors and contribute to understanding a novel pathway to adiposity.

County-Level Clustering and Characteristics of Repeat Versus First Teen Births in the United States, 2015-2017.

PURPOSE: Approximately 16% of U.S. births to women aged 15-19 years are repeat (second or higher order) births. Repeat teen mothers are at elevated risk for poor perinatal outcomes. Geographic clustering and correlates of repeat teen birth are unknown. METHODS: Data from birth certificates on N = 629,939 teen births in N = 3,108 U.S. counties in 2015-2017 were merged with data on county-level demographic, socioeconomic, and health provider characteristics. We identified contiguous clusters of counties with significantly elevated rates of first teen births only, repeat teen births, both, or neither between 2015 and 2017 and compared demographic, socioeconomic, and medical provider characteristics of counties between 2010 and 2016 in each cluster type. RESULTS: A total of 193 counties (6.21%) had high rates of repeat births only; 504 (16.22%) had high rates of first teen birth only; 991 (31.89%) had high rates of both repeat and first teen births; and 1,420 (45.69%) had neither. Counties with high repeat (vs. first only) birth rates had higher rates of poverty and unemployment, higher levels of income inequality, lower high school graduation rates, a higher share of racial and ethnic minority residents, fewer publicly funded family planning clinics per capita, and more women receiving contraceptive services at publicly funded clinics. CONCLUSIONS: First and repeat teen births cluster in differentially resourced geographic areas. Counties with high repeat teen birth rates have lower socioeconomic conditions than counties with high rates of first teen births only. These counties are more reliant on publicly funded family planning clinics but have fewer of them per capita.