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Summary: While California as a whole has made significant progress over the past three decades in reducing rates of cigarette smoking, progress across communities in the state has been uneven.1 Using the 2014–2019 California Health Interview Survey (CHIS) combined adult data and existing state, county, and city tobacco control policies and neighborhood-level data on social drivers of health, this brief examines variations in local tobacco policies and their relationship with smoking behaviors, particularly among priority populations disproportionately impacted by tobacco. Findings: In 2019, more than 60% of California cities still had weak or no local tobacco policies. Inequities in protection by tobacco control policies persist across priority populations, especially in areas with low neighborhood socioeconomic status (NSES). Reductions in adult cigarette smoking were greater in cities with strong local tobacco policies than in those with weak or no policies. Strong local policies were also associated with decreased smoking rates among adult (18+) populations disproportionately impacted by the tobacco epidemic, thereby reducing social inequalities in cigarette smoking. This study also found that the positive effect of local tobacco control policies on current adult smoking rates was further enhanced when the state-level tobacco policy (i.e., raising the tax from $0.87 to $2.87 per pack) was enacted in April 2017.

Public health and transportation literature documents links between walking and overall wellbeing among people of all ages. However, quantifications of these links frequently reflect only one type of walking, such as exercise walking or walking for transportation. Often, this work concentrates on healthy, working age adults. This results in limited understanding of how total walking cumulatively relates to overall health status, especially among other populations. Demographic shifts in the United States will result in population aging, which informs a sense of urgency around understanding how older and more disability-burdened groups will engage in walking, and how socioeconomic contexts in which they reside will shape these patterns. This dissertation used data from the 2017 National Household Travel Survey, which measures travel behaviors to quantify total walking patterns among subsamples of older adults, people with disabilities, and young adults. Each of the three interrelated studies used a theoretical framework informed by the Life Course Perspective and Social Ecological Model to develop multivariable statistical models predicting walking outcomes. Findings indicate that older adult walking frequency correlates most strongly with gender, overall health status, and household vehicle access. Mobility disability status, overall health status, use of mobility devices, and educational attainment were also highly correlated with any walking among older adults. Among disabled and non-disabled working-age adults, number of household vehicles and population density of residential area correlated with total weekly walk count; health and disability statuses did not. Mobility disability and health statuses did, however, predict odds of participation in any total walking in the past week among this group. Among young adults (18-25,) patterns in total walking vary according to immigrant status. Each study contextualizes these results and potential applications to public h

BACKGROUND: Primary Health Care (PHC) is essential for effective, efficient, and more equitable health systems for all people, including those living with HIV/AIDS. This study evaluated the impact of the exposure to one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. METHODS AND FINDINGS: A retrospective cohort study carried out in Brazil from January 1, 2007 to December 31, 2015. We conducted an impact evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the impact of FHS on AIDS incidence and mortality and compared outcomes between residents of municipalities with low or no FHS coverage (unexposed) with those in municipalities with 100% FHS coverage (exposed). We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated the FHS impact by sex and age and performed a wide range of sensitivity and triangulation analyses; 100% FHS coverage was associated with lower AIDS incidence (rate ratio [RR]: 0.76, 95% CI: 0.68 to 0.84) and mortality (RR: 0.68, 95%CI: 0.56 to 0.82). FHS impact was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR: 0.62, 95% CI: 0.53 to 0.72) and mortality (RR: 0.56, 95% CI: 0.43 to 0.72). The absence of important confounding variables (e.g., sexual behavior) is a key limitation of this study. CONCLUSIONS: AIDS should be an avoidable outcome for most people living with HIV today and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promot

ObjectivesThe Brazilian Family Health Strategy (FHS) is strongly associated with better health system performance, but there are no nationally-representative data examining individual-level primary care experiences in the country. Here, we examine reports of primary care experiences among adults with different forms of healthcare coverage (FHS, "traditional" public health posts, and private health plans).MethodsData are from the 2019 National Health Survey that included a shortened version of the Primary Care Assessment Tool (PCAT). PCAT questions were administered to a subsample of randomly-selected adults who had a doctor visit within the past 6 months and sought care in a primary care setting (9677 respondents). We used linear regression to examine the association between type of healthcare coverage and PCAT scores adjusted for sex, age, socioeconomic status, health status, geographic region and state of residence.ResultsPrimary care experiences in the sample of Brazilians who had a doctor visit 6 months prior to the survey averaged a modest PCAT score of 57 out of 100. Regression models show that users of the FHS had superior primary care experiences, but with large variations across Brazilian regions and states. Individuals selected to respond to the PCAT questions were more likely to be female, older, and poorer, and to be in worse health than the general population.ConclusionsBrazil's FHS is associated with modest, but higher-reported primary care experiences than both traditional public health posts and those who have a private health plan. Future iterations of the PCAT module could enhance generalizability by including individuals who had a doctor visit in the past 12 (instead of 6) months.

ObjectivesThe Brazilian Family Health Strategy (FHS) is strongly associated with better health system performance, but there are no nationally-representative data examining individual-level primary care experiences in the country. Here, we examine reports of primary care experiences among adults with different forms of healthcare coverage (FHS, "traditional" public health posts, and private health plans).MethodsData are from the 2019 National Health Survey that included a shortened version of the Primary Care Assessment Tool (PCAT). PCAT questions were administered to a subsample of randomly-selected adults who had a doctor visit within the past 6 months and sought care in a primary care setting (9677 respondents). We used linear regression to examine the association between type of healthcare coverage and PCAT scores adjusted for sex, age, socioeconomic status, health status, geographic region and state of residence.ResultsPrimary care experiences in the sample of Brazilians who had a doctor visit 6 months prior to the survey averaged a modest PCAT score of 57 out of 100. Regression models show that users of the FHS had superior primary care experiences, but with large variations across Brazilian regions and states. Individuals selected to respond to the PCAT questions were more likely to be female, older, and poorer, and to be in worse health than the general population.ConclusionsBrazil's FHS is associated with modest, but higher-reported primary care experiences than both traditional public health posts and those who have a private health plan. Future iterations of the PCAT module could enhance generalizability by including individuals who had a doctor visit in the past 12 (instead of 6) months.

BACKGROUND: Poverty and social inequality are risk factors for poor health outcomes in patients with HIV/AIDS. In addition to eligibility, cash transfer programmes can be divided into two categories: those with specific requirements (conditional cash transfers [CCTs]) and those without specific requirements (unconditional cash transfers). Common CCT requirements include health care (eg, undergoing an HIV test) and education (eg, children attending school). Trials assessing the effect of cash transfer programmes on HIV/AIDS outcomes have yielded divergent findings. This review aimed to summarise evidence to evaluate the effects of cash transfer programmes on HIV/AIDS prevention and care outcomes. METHODS: For this systematic review and meta-analysis, we searched PubMed, EMBASE, Cochrane Library, LILACS, WHO IRIS, PAHO-IRIS, BDENF, Secretaria Estadual de Saúde SP, Localizador de Informação em Saúde, Coleciona SUS, BINACIS, IBECS, CUMED, SciELO, and Web of Science up to Nov 28, 2022. We included randomised controlled trials (RCTs) that evaluated the effects of cash transfer programmes on HIV incidence, HIV testing, retention in HIV care, and antiretroviral therapy adherence, and conducted risk of bias and quality of evidence assessments using the Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations approach. A random-effects meta-analysis model was used to combine studies and calculate risk ratios (RRs). Subgroup analyses were performed using conditionality types (ie, school attendance or health care). The protocol was registered with PROSPERO, CRD42021274452. FINDINGS: 16 RCTs, which included 5241 individuals, fulfilled the inclusion criteria. Of these, 13 studies included conditionalities for receiving cash transfer programmes. The results showed that receiving a cash transfer was associated with lowered HIV incidence among individuals who had to meet health-care conditionalities (RR 0·74, 95% CI 0·56-0·98) and with

BACKGROUND: Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.). METHODS: We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies. RESULTS: Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30. CONCLUSIONS: Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

A growing literature has explored the relationship between life course factors and health in later life. In particular, childhood circumstances have been shown to be associated with several health outcomes many decades later. Most of this literature has focused on high-income countries and on associations between single events or exposure variables in childhood and individual health outcomes among older adults. Less is known about the combined effect of harmful exposure in childhood on later-life health outcomes and, especially, in lower- and middle-income countries. Also, imperfect strategy identifications in observational studies make difficult to assess the robustness of these associations. This dissertation aims to address this gap in the literature with three separate studies on the relationship between childhood disadvantage and several later-life health outcomes among Brazilians aged 50 and over using data from the baseline assessment of the Brazilian Longitudinal Study of Aging. The first study sheds light on the associations between several potentially harmful exposures in childhood (separately and combined) and the occurrence of chronic conditions, separately and together (multimorbidity). The second study focuses on the impact on distinct theoretically appropriate domains of childhood disadvantage on three measures of cognitive performance. These first two studies also investigate the potential mediation effect of adulthood socioeconomic status (SES) on these relationships. And the last study discusses the appropriateness of a novel sensitivity framework (SenseMakr) to analyze observational studies by analyzing the robustness of 65 hypothesized associations between individual exposure and outcome variables. Results from the first study shows that a childhood disadvantage scale was associated with 8 different chronic conditions as well as the total count of chronic conditions. Mediation analyses suggest that part of the effect of childhood disadvantage (10

BACKGROUND: Social determinants of health (SDH) include factors such as income, education, and race, that could significantly affect the human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS). Studies on the effects of SDH on HIV/AIDS are limited, and do not yet provide a systematic understanding of how the various SDH act on important indicators of HIV/AIDS progression. We aimed to evaluate the effects of SDH on AIDS morbidity and mortality. METHODS: A retrospective cohort of 28.3 million individuals was evaluated over a 9-year period (from 2007 to 2015). Multivariable Poisson regression, with a hierarchical approach, was used to estimate the effects of SDH-at the individual and familial level-on AIDS incidence, mortality, and case-fatality rates. FINDINGS: A total of 28,318,532 individuals, representing the low-income Brazilian population, were assessed, who had a mean age of 36.18 (SD: 16.96) years, 52.69% (14,920,049) were female, 57.52% (15,360,569) were pardos, 34.13% (9,113,222) were white/Asian, 7.77% (2,075,977) were black, and 0.58% (154,146) were indigenous. Specific socioeconomic, household, and geographic factors were significantly associated with AIDS-related outcomes. Less wealth was strongly associated with a higher AIDS incidence (rate ratios-RR: 1.55; 95% confidence interval-CI: 1.43-1.68) and mortality (RR: 1.99; 95% CI: 1.70-2.34). Lower educational attainment was also greatly associated with higher AIDS incidence (RR: 1.46; 95% CI: 1.26-1.68), mortality (RR: 2.76; 95% CI: 1.99-3.82) and case-fatality rates (RR: 2.30; 95% CI: 1.31-4.01). Being black was associated with a higher AIDS incidence (RR: 1.53; 95% CI: 1.45-1.61), mortality (RR: 1.69; 95% CI: 1.57-1.83) and case-fatality rates (RR: 1.16; 95% CI: 1.03-1.32). Overall, also considering the other SDH, individuals experiencing greater levels of socioeconomic deprivation were, by far, more likely to acquire AIDS, and to die from it. INTERPRETATION: In the population stu

OBJECTIVE: To investigate the relationship between of distinct domains of childhood disadvantage and cognitive performance among older adults within the context of a middle-income country. METHODS: This study used baseline data (2015/2016) from the Brazilian Longitudinal Study of Aging (ELSI), a nationally representative cohort of 9412 adults aged 50 and over. Nine childhood exposure variables were grouped into three domains (family SES, childhood health, and cultural capital), for which scores were created. Survey-weighted Ordinary Least Squares (OLS) regressions estimated the association childhood disadvantage with cognitive performance as measured by immediate memory, late memory and semantic verbal fluency. Mediation analysis assessed whether adulthood socioeconomic status (SES) mediated this relationship of interest. RESULTS: Important disparities in cognitive performance were observed, particularly in terms of age, education, income, occupational status. Before controlling for adulthood SES in the multivariable analysis, all domains of childhood disadvantage were found to be associated with lower cognitive performance across all three measures. After inclusion of adulthood SES variables, the observed associations only remained for semantic verbal fluency. Formal mediation analysis indicated that adulthood SES mediates 47.9% (95% CI: 34.3%-78.6%) of the association between later-life verbal fluency and poor childhood health, and 49.9% (95% CI: 43.6%-57.8%) of the association between later-life verbal fluency and low childhood cultural capital. CONCLUSIONS: We found that childhood disadvantage is associated with low performance in memory tests and semantic verbal fluency tests among older Brazilians. Adulthood SES fully mediated the association between all domains of childhood disadvantage and memory performance and only partially mediated its association with verbal fluency. Our findings support policy efforts to enhance early childhood development and improve

Building fair, equitable, and beneficial partnerships between institutions collaborating in research in low- and middle-income countries (LMIC) and high-income countries (HIC) has become an integral part of research capacity building in global health in recent years. In this paper, we offer an example of an academic collaboration between the University of California Los Angeles, Center for Health Policy and Research (UCLA CHPR) and the University of Philippines, Manila, College of Public Health (UPM CPH) that sought to build an equitable partnership between research institutions. The partnership was built on a project to build capacity for research and produce data for policy action for the prevention and care of non-communicable diseases (NCDs) through primary healthcare in the Philippines. The specific objectives of the project were to: (1) locally adapt the Primary Care Assessment Tool for the Philippines and use the adapted tool to measure facility-level primary care delivery, (2) conduct focus group discussions (FGDs) to gather qualitative observations regarding primary care readiness and capacity, and (3) conduct a comprehensive population-based health survey among adults on NCDs and prior healthcare experience. We describe here the progression of the partnership between these institutions to carry out the project and the elements that helped build a stronger connection between the institutions, such as mutual goal setting, cultural bridging, collaborative teams, and capacity building. This example, which can be used as a model depicting new directionality and opportunities for LMIC-HIC academic partnerships, was written based on the review of shared project documents, including study protocols, and written and oral communications with the project team members, including the primary investigators. The innovation of this partnership includes: LMIC-initiated project need identification, LMIC-based funding allocation, a capacity-building role of the HIC instituti

ObjectivesVaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults.DesignCross-sectional analysis of data from household interviews and a supplementary telephone survey.SettingBrazil and its five geographic regions.ParticipantsData are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging.Primary and secondary outcome measuresSurvey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one's intention to vaccinate against COVID-19.FindingsSeventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal.ConclusionsMost national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a

ObjectivesVaccine hesitancy may represent a barrier to effective COVID-19 immunisation campaigns. This study assesses individual, disease-specific and contextual factors associated with COVID-19 vaccine acceptance among a nationally representative sample of older Brazilian adults.DesignCross-sectional analysis of data from household interviews and a supplementary telephone survey.SettingBrazil and its five geographic regions.ParticipantsData are derived from 6584 individuals aged 50 years and over who participated in the second wave of the Brazilian Longitudinal Study of Aging.Primary and secondary outcome measuresSurvey-weighted multinomial logistic regression assesses factors associated with intending, not intending or being uncertain about one's intention to vaccinate against COVID-19.FindingsSeventy-one per cent of study participants intend to receive a COVID-19 vaccine once available, while 17% (representative of nearly 9 million people) have no intention to vaccinate, and 12% are still undecided. Besides age, demographic and health-related factors related to COVID-19 severity and complications were not associated with intention to vaccinate. Those who most trusted social media or friends and family for COVID-19 information and those who did not trust any information source were 68% and 78% more likely to refuse vaccination, respectively, as compared with those who trusted official information sources. People who inconsistently used face masks when outside were 3.4 times more likely than consistent face mask users to intend to refuse vaccination. Higher municipal COVID-19 fatality rates were negatively associated with vaccine refusal.ConclusionsMost national COVID-19 immunisation strategies identify older individuals as among those prioritised for early vaccination, given their increased risk of more severe symptoms and complications of the disease. Because individual, disease-specific, and contextual factors were associated with vaccine acceptance, there is a

BackgroundMultiple risk factors accumulate over the life-course and contribute to higher rates of disability at older ages. This study investigates whether three life-course risk factors (low educational attainment, poor health in childhood and multimorbidity) are associated with increased risk of disability [defined as any limitation in basic activities of daily living (BADL)] in older adults and whether this relationship is moderated by the national socioeconomic context, measured by the Human Development Index (HDI).MethodsData include 100 062 adults (aged 50 and over) participating in longitudinal studies of aging conducted in 19 countries. Analyses include multivariable Poisson models with robust standard errors to assess the associations between HDI, life-course risk factors and other individual-level control variables (sex and age) with any BADL disability.ResultsIn country-specific analyses, both educational attainment and multimorbidity are independently associated with disability in nearly every country. The interaction between these risk factors further increases the magnitude of this association. In pooled regression analyses, the relationship between life-course risk factors and disability is moderated by a country's HDI. For individuals with all three life-course risk factors, the predicted probability of disability ranged from 36.7% in the lowest HDI country to 21.8% in the highest HDI country.ConclusionsSocial and health system policies directed toward reducing the development of life-course risk factors are essential to reduce disability in all countries, but are even more urgently needed in those with lower levels of socioeconomic development.

Countries around the world have committed to achieving universal health coverage as part of the Sustainable Development Goals agreed upon by all United Nations members, intended to be achieved by 2030. But important population groups such as older adults are rarely examined as part of Sustainable Development Goals monitoring and evaluation efforts. This study uses recent (2014-16) high-quality, individual-level data from several aging cohorts representing more than 100,000 adults ages fifty and older in twenty-three high- and middle-income countries. After individual characteristics and health needs were controlled for, national rates varied up to tenfold for poor access (no doctor visit) and threefold for potential overutilization (fifteen or more doctor visits and multiple hospitalizations) in the past year. Catastrophic expenditures (25 percent or more of household income spent out of pocket on health care) averaged 9 percent, with the highest rates observed in middle-income countries and among sicker populations in some high-income countries. Strengthening universal health coverage for older adults will require greater tailoring and targeting of benefits to meet this population's health needs while protecting them from catastrophic health expenditures.

The China Healthy Cities (Counties) public health initiative has been at the forefront of China's efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored. We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed. We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI -1.2 to -0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI -2.2 to -0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications. Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions. Future research could explore differen

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose-response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

BackgroundDespite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world's largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS).ObjectiveWe will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations.Methods and analysisWe will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the "100 Million Brazilian Cohort", over a 19-year period (2000-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios.ConclusionThe unprecedent

The China Healthy Cities (Counties) public health initiative has been at the forefront of China's efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored. We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed. We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI -1.2 to -0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI -2.2 to -0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications. Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions. Future research could explore differen

(1) Background: Brazil has a universal public healthcare system, but individuals can still opt to buy private health insurance and/or pay out-of-pocket for healthcare. Past research suggests that Brazilians make combined use of public and private services, possibly causing double costs. This study aims to describe this dual use and assess its relationship with socioeconomic status (SES). (2) Methods: We calculated survey-weighted population estimates and descriptive statistics, and built a survey-weighted logistic regression model to explore the effect of SES on dual use of healthcare, including demographic characteristics and other variables related to healthcare need and use as additional explanatory variables using data from the 2019 Brazilian National Health Survey. (3) Results: An estimated 39,039,016 (n = 46,914; 18.6%) persons sought care in the two weeks before the survey, of which 5,576,216 were dual users (n = 6484; 14.7%). Dual use happened both in the direction of public to private (n = 4628; 67.3%), and of private to public (n = 1855; 32.7%). Higher income had a significant effect on dual use (p < 0.0001), suggesting a dose-response relationship, even after controlling for confounders. Significant effects were also found for region (p < 0.0001) and usual source of care (USC) (p < 0.0001). (4) Conclusion: A large number of Brazilians are seeking care from a source different than their regular system. Higher SES, region, and USC are associated factors, possibly leading to more health inequity. Due to its high prevalence and important implications, more research is warranted to illuminate the main causes of dual use.

BackgroundDespite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world's largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS).ObjectiveWe will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations.Methods and analysisWe will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the "100 Million Brazilian Cohort", over a 19-year period (2000-2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios.ConclusionThe unprecedent

BackgroundAsthma disproportionately affects individuals with lower income. High uninsured rates are a potential driver for this disparity. Previous studies have not examined the effect of the Affordable Care Act (ACA) on asthma-related outcomes for individuals with low income.Research questionWhat is the impact of insurance status and the ACA on asthma outcomes for adults 18 to 64 years of age in households with low-income status?Study design and methodsThis study was a pooled cross-sectional observational study using National Health Interview Survey data from 2011 through 2013 and 2016 through 2018. Individuals 18 to 64 years of age with a history of asthma and low income were included. Survey-weighted regression modeling and mediation analysis was used to explore the relationship of insurance status and asthma control. Univariate and multivariate survey-weighted regression modeling then was used to evaluate the correlation of the ACA and asthma outcomes.ResultsWe identified 4,043 individual observations. Having health insurance was correlated with improved asthma outcomes (OR, 1.25). This relationship was completely mediated by cost barriers to medications and physician visits. Although the ACA resulted in significant changes in insurance status (OR, 2.4), no statistically significant change was found in asthma outcomes. Furthermore, cost barriers to both medications and physician visits persisted in the insured population, 20.7% and 30.0%, respectively.InterpretationInsurance coverage is associated with improved asthma control for adults 18 to 64 years from households with low socioeconomic status. The ACA reduced the rates of uninsured, but did not have the same magnitude of effect on reducing cost barriers. The persistence of cost barriers may explain in part the lack of population-level improvement in asthma control.

Currently, it is estimated that 37.6 million people are living with the HIV/AIDS virus worldwide, placing HIV/AIDS among the ten leading causes of death, mostly among low- and lower-middle-income countries. Despite the effective intervention in the prevention and treatment, this reduction did not occur equally among populations, subpopulations and geographic regions. This difference in the occurrence of the disease is associated with the social determinants of health (SDH), which could affect the transmission and maintenance of HIV. With the recognition of the importance of SDH in HIV transmission, the development of mathematical models that incorporate these determinants could increase the accuracy and robustness of the modeling. This article aims to propose a theoretical and conceptual way of including SDH in the mathematical modeling of HIV/AIDS. The theoretical mathematical model with the Social Determinants of Health has been developed in stages. For the selection of SDH that were incorporated into the model, a narrative literature review was conducted. Secondly, we proposed an extended model in which the population (N) is divided into Susceptible (S), HIV-positive (I), Individual with AIDS (A) and individual under treatment (T). Each SDH had a different approach to embedding in the model. We performed a calibration and validation of the model. A total of 31 SDH were obtained in the review, divided into four groups: Individual Factors, Socioeconomic Factors, Social Participation, and Health Services. In the end, four determinants were selected for incorporation into the model: Education, Poverty, Use of Drugs and Alcohol abuse, and Condoms Use. the section "Numerical simulation" to simulate the influence of the poverty rate on the AIDS incidence and mortality rates. We used a Brazilian dataset of new AIDS cases and deaths, which is publicly available. We calibrated the model using a multiobjective genetic algorithm for the years 2003 to 2019. To forecast from 2

BACKGROUND: One of the biggest challenges of the response to the AIDS epidemic is to reach the poorest people. In 2004, Brazil implemented one of the worlds largest conditional cash transfer programmes, the Bolsa Família Programme (BFP). We aimed to evaluate the effect of BFP coverage on AIDS incidence, hospitalisations, and mortality in Brazil. METHODS: In this longitudinal ecological study, we developed a conceptual framework linking key mechanisms of BFP effects on AIDS indicators and used ecological panel data from 5507 Brazilian municipalities over the period of 2004-18. We used government sources to calculate municipal-level AIDS incidence, hospitalisation, and mortality rates, and used multivariable regressions analyses of panel data with fixed-effects negative binomial models to estimate the effect of BFP coverage, which was classified as low (0-29%), intermediate (30-69%), and high (≥70%), on AIDS indicators, while adjusting for all relevant demographic, socioeconomic, and health-care covariates at the municipal level. FINDINGS: Between 2004 and 2018, in the municipalities under study, 601 977 new cases of AIDS were notified, of which 376 772 (62·6%) were in males older than 14 years, 212 465 (35·3%) were in females older than 14 years, and 12 740 (2·1%) were in children aged 14 years or younger. 533 624 HIV/AIDS-related hospitalisations, and 176 868 AIDS-related deaths had been notified. High BFP coverage was associated with reductions in incidence rate ratios of 5·1% (95% CI 0·9-9·1) for AIDS incidence, 14·3% (7·7-20·5) for HIV/AIDS hospitalisations, and 12·0% (5·2-18·4) for AIDS mortality. The effect of the BFP on AIDS indicators was more pronounced in municipalities with higher AIDS endemicity levels, with reductions in incidence rate ratios of 12·7% (95% CI 5·4-19·4) for AIDS incidence, 21·1% (10·7-30·2) for HIV/AIDS hospitalisations, and 14·7% (3·2-24·9) for AIDS-related mortality, and reductions in AIDS incidence of 14·6% (5·9-22·5) in females older

Introduction The China Healthy Cities (Counties) public health initiative has been at the forefront of China’s efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored. Methods We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed. Results We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI −1.2 to −0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI −2.2 to −0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications. Conclusion Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions

ObjectivesTo describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments.MethodsCross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care.ResultsThe prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams.ConclusionsMultimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

ObjectivesTo describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments.MethodsCross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care.ResultsThe prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams.ConclusionsMultimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

ObjectiveTo assess the association between short maternal height and four types of mother-child nutritional status groupings within Mexican households.DesignWe classified mother-child dyads into four groups: stunted child and a non-overweight/non-obese mother (stunting-only), non-stunted child and an overweight/obese mother (overweight-only), stunted child with an overweight/obese mother (double-burden) and households with neither child stunting nor overweight/obese mothers (neither-condition). We assessed the association between maternal height and mother-child nutrition status using multinomial logistic regression, controlling for socio-economic covariates.SettingNationally representative cross-section of households from the 2012 Mexican National Health and Nutrition Survey.ParticipantsChildren <5 years of age were matched to their mothers, resulting in a sample of 4706 mother-child dyads.ResultsWe found that among children with stunting, 53·3% have an overweight/obese mother. Double-burden was observed in 8·1% of Mexican households. Maternal short stature increased the probability of stunting-only by 3·5% points (p.p.) and double-burden by 9·7 p.p. (P < 0·05). The inverse association was observed for overweight-only and neither-condition households, where the probability of these outcomes decreased by 7·2 and 6 p.p. in households with short-statured mothers (P < 0·05), respectively.ConclusionsWomen with short stature are more likely to develop overweight and simultaneously have a stunted child than those who are not short-statured. Our findings underline the challenges faced by public health systems, which have to balance the provision of services for both an undernourished and increasingly overweight/obese population.

While the influenza vaccine is recommended for all pregnant women, influenza vaccine coverage among this high-risk population remains inadequate. Factors associated with vaccine coverage among pregnant women, including insurance status, are poorly understood. In a cross-sectional study of the National Health Interview Survey (NHIS) data from 2012 to 2018, we evaluated predictors of self-reported influenza vaccine coverage in pregnant women. Among 1,942 pregnant women surveyed, 39% reported receiving the influenza vaccine in accordance with national recommendations. Influenza vaccine coverage increased by 8 percentage points from 2012 to 2018. Only 15% of uninsured pregnant women received the influenza vaccine, compared to 41% of those with insurance (design-corrected F-test, p-value < 0.001). In the multivariate Poisson regression analysis, significant predictors of influenza vaccine coverage were health insurance (prevalence ratio [PR] 1.90, 95% confidence interval [CI] 1.23-2.93), ratio of household income to federal poverty level (FPL) threshold greater than 400% (PR 1.54, 95% CI 1.20-1.96), graduate school education (PR 1.52, 95% CI 1.04-2.23), and the 2015-2018 survey year period (PR 1.27, 95% CI 1.08-1.49). While previous literature focuses heavily on demographics, our research underscores the need to further explore modifiable factors that impact vaccine uptake during pregnancy, particularly the interplay between health insurance and access to care.

Trust, particularly during emergencies, is essential for effective health care delivery and health policy implementation. We used data from the 2018 Wellcome Global Monitor survey (comprising nationally representative samples from 144 countries) to examine levels and correlates of trust in governments and health workers and attitudes toward vaccines. Only one-quarter of respondents globally expressed a lot of trust in their government (trust was more common among people with less schooling, those living in rural areas, those who were financially comfortable, and those who were older), and fewer than half of respondents globally said that they trust doctors and nurses a lot. People's trust in these institutions was correlated with trust in health or medical advice from them, and with more positive attitudes toward vaccines. Vaccine enthusiasm varied substantially across regions, with safety being the most common concern. Policy makers should understand that the public may have varying levels of trust in different institutions and actors. Although much attention is paid to crafting public health messages, it may be equally important, especially during a pandemic, to identify appropriate, trusted messengers to deliver those messages more effectively to different target populations.

ObjectiveTo characterize healthcare access and utilization among older Brazilians.MethodsData are from the baseline wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), which is a nationally representative, population-based cohort study of persons aged 50 years and older conducted in 2015/2016 (n = 9,412). The prevalence of barriers to primary care and number and type of doctor visits in the past 12 months are compared by three main sources of healthcare (private, Family Health Strategy, traditional public clinics). Two-part multivariable hurdle analyses assess the relation between healthcare utilization, primary care problems, and source of healthcare, while controlling for healthcare determinants.ResultsFemales comprised 54% of the sample, with a mean age of 63 years. There were no demographic differences by source of healthcare. Nearly 83% had at least one doctor visit in the past 12 months, with higher use among private health plan holders. Private health plan holders most frequently visited specialists, while those using the public system were more likely to visit a general practitioner. Primary care barriers averaged 3.5 out of 12 and were the highest among those using traditional health posts. A greater number of primary care problems was negatively associated with all types of healthcare utilization.ConclusionsBy international standards, access to basic healthcare among older Brazilians is relatively high. Nevertheless, different levels of primary care problems between the public and private sectors and resulting utilization patterns suggest the need to continue working to close remaining gaps.

ObjectiveTo characterize healthcare access and utilization among older Brazilians.MethodsData are from the baseline wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), which is a nationally representative, population-based cohort study of persons aged 50 years and older conducted in 2015/2016 (n = 9,412). The prevalence of barriers to primary care and number and type of doctor visits in the past 12 months are compared by three main sources of healthcare (private, Family Health Strategy, traditional public clinics). Two-part multivariable hurdle analyses assess the relation between healthcare utilization, primary care problems, and source of healthcare, while controlling for healthcare determinants.ResultsFemales comprised 54% of the sample, with a mean age of 63 years. There were no demographic differences by source of healthcare. Nearly 83% had at least one doctor visit in the past 12 months, with higher use among private health plan holders. Private health plan holders most frequently visited specialists, while those using the public system were more likely to visit a general practitioner. Primary care barriers averaged 3.5 out of 12 and were the highest among those using traditional health posts. A greater number of primary care problems was negatively associated with all types of healthcare utilization.ConclusionsBy international standards, access to basic healthcare among older Brazilians is relatively high. Nevertheless, different levels of primary care problems between the public and private sectors and resulting utilization patterns suggest the need to continue working to close remaining gaps.

Bullying during childhood and adolescence can negatively influence various aspects of youth development and long-term well-being. Adults who were bullied as children or adolescents are more likely to struggle with mental health problems such as panic disorders and anxiety, while adolescent bullies are more likely to engage in violent behaviors later in life. Yet, bullying is a common experience for many youths around the world and global surveys estimate that approximately one in three adolescent males and one in four females have been the target of bullying at school. This dissertation focuses on adolescent bullying in Latin America and the Caribbean, a region of the world affected by high levels of intentional violence among youth, but that so far has been relatively under-researched. Together, these three papers explore the role of socioeconomic factors at the individual and school levels and assess the national policy landscape in the region. The first paper focuses on the relationship between student socioeconomic status and different dimensions of bullying victimization (e.g. physical and verbal). The second paper investigates how the school’s socioeconomic context relates to student bullying victimization. These two papers use data from the 2015 Program for International Student Assessment (PISA). The third paper provides an overview of the antibullying legislative context in Latin America and the Caribbean. This paper includes a descriptive analysis of existing school-based antibullying laws and uses both empirical and iterative methods to create a quantitative legal dataset, which is subsequently used to assess the scope of existing laws, bullying definitions, and preventive measures. Analyses of the PISA data reveal a sizeable number of missing data, especially among more vulnerable students. Data completeness also varies across participating countries. These findings highlight the difficulties of conducting large international assessments and should suppo

BackgroundWhile in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally.MethodsWe conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country.ResultsPossible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight.ConclusionsThe review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high politi

Bullying during childhood and adolescence can negatively influence various aspects of youth development and long-term well-being. Adults who were bullied as children or adolescents are more likely to struggle with mental health problems such as panic disorders and anxiety, while adolescent bullies are more likely to engage in violent behaviors later in life. Yet, bullying is a common experience for many youths around the world and global surveys estimate that approximately one in three adolescent males and one in four females have been the target of bullying at school. This dissertation focuses on adolescent bullying in Latin America and the Caribbean, a region of the world affected by high levels of intentional violence among youth, but that so far has been relatively under-researched. Together, these three papers explore the role of socioeconomic factors at the individual and school levels and assess the national policy landscape in the region. The first paper focuses on the relationship between student socioeconomic status and different dimensions of bullying victimization (e.g. physical and verbal). The second paper investigates how the school’s socioeconomic context relates to student bullying victimization. These two papers use data from the 2015 Program for International Student Assessment (PISA). The third paper provides an overview of the antibullying legislative context in Latin America and the Caribbean. This paper includes a descriptive analysis of existing school-based antibullying laws and uses both empirical and iterative methods to create a quantitative legal dataset, which is subsequently used to assess the scope of existing laws, bullying definitions, and preventive measures. Analyses of the PISA data reveal a sizeable number of missing data, especially among more vulnerable students. Data completeness also varies across participating countries. These findings highlight the difficulties of conducting large international assessments and should suppo

BackgroundWhile in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally.MethodsWe conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country.ResultsPossible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight.ConclusionsThe review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high politi

Despite some remarkable achievements, there are several challenges facing Brazil's Family Health Strategy (FHS), including expanding access to primary care and improving its quality. These concerns motivated the development of the National Program for Improving Primary Care Access and Quality (PMAQ). Although voluntary, the program now includes nearly 39 000 FHS teams in the country and has led to a near doubling of the federal investment in primary care in its first 2 rounds. In this article, we introduce the PMAQ and advance several recommendations to ensure that it continues to improve primary care access and quality in Brazil.

BackgroundPrevious studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.MethodsWe estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.ResultsThe U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.ConclusionsThis study demonstrates that increased health professionals were associated with reductions in U5MR. The largest associati

BACKGROUND:Prior research suggests that undernutrition and enteric infections predispose children to stunted growth. Undernutrition and infections have been associated with limited access to healthy diets, lack of sanitation, and access barriers to healthcare - all associated with human rights. Stunting has also been documented to be a major determinant of subsequent obesity and non-communicable diseases. Short leg length relative to stature during adulthood seems to be a good proxy indicator tracking such barriers, and has been reported to be associated with adverse health effects during adulthood. Our objective was to examine the association between relative leg length (as measured by the leg length index, LLI) and measures of adiposity - based on body mass index (BMI) and waist circumference (WC) - in a population of recent Mexican immigrant women to the New York City Area. METHODS:The analysis was based on a cross-sectional survey of 200 Mexican immigrant women aged 18 to 70 years, whose data were collected between April and November 2008; although for purposes of the current study we restricted the sample to those aged 18 to 59 years. The dependent variables were BMI and WC, both transformed into categorical variables. The main independent variable was LLI, and other correlates were controlled for (i.e. age, education, having had children, characteristics of the community of origin, acculturation, chronic conditions, sedentary behaviors, access to fresh fruits and vegetables). Two probit models were estimated: the first one analyzed the effect of LLI on BMI categories and the second one estimated the effect of LLI on WC. RESULTS:The probit assessing the effect of LLI on overweight/obesity suggested that having a short LLI increased the probability of overweight/obesity by 21 percentage points. Results from the probit model estimating the effect of LLI on WC indicated that having a short LLI increased the probability of having abdominal adiposity by 39 percentag

Excessive alcohol consumption contributes significantly to premature mortality, injuries and morbidity, and a range of U.S. state policies have been shown to reduce these behaviors. Monitoring state alcohol policy environments is essential, but methodologically challenging given that new laws may be passed (or repealed) each year, resulting in considerable variation across states. Existing measures have not been made public or have only a single year available. We develop a new replicable measure, the state alcohol policy score, for each state and year 2004-2009, that captures the essential features of a state's evidence-based alcohol policies. We evaluate its similarity to two existing alcohol policy measures and validate it by replicating findings from a previous study that used one of those measures to assess its relationship with several binge drinking outcomes. Estimates of the association between one-year lagged state alcohol policy scores and state binge drinking outcomes, obtained from the 2005-2010 Behavioral Risk Factor Surveillance System surveys (n = 440,951, 2010), were produced using Generalized Linear Models that controlled for state and individual-level co-variates, with fixed effects for year and region. We find a 10-percentage point increase in the state alcohol policy score was associated with a 9% lower odds of binge drinking (aOR = 0.91, 95% CI 0.89, 0.92; N = 1,992,086), a result consistent for men, women and for most age and race subgroups. We find that gender gaps in binge drinking behaviors narrowed in states with higher state alcohol policy scores. These results were nearly identical to those found in other studies using different scores obtained with the aid of expert opinions. We conclude that the score developed here is a valid measure that can be readily updated for monitoring and evaluating the variation and impact of state alcohol policies and make available our state scores for the years of the study.

BackgroundPrevious studies have focused on the relationship between increases in the health care workforce and child health outcomes, but little is known about how this relationship differs in contexts where economic growth differs by initial level and pace. This study evaluates the association between increased health professionals and the under-five mortality rate (U5MR) in rural Chinese counties from 2008 to 2014 and examines whether this relationship differs among counties with different patterns of economic growth over this period.MethodsWe estimated fixed effects models with rural counties as the unit of analysis to evaluate the association between health professional density and U5MR. Covariates included county-level gross domestic product (GDP) per capita, female illiteracy rate, value of medical equipment per bed, and province-level health expenditures (measured as a proportion of provincial GDP). To explore modification effects, we assessed interactions between health professionals and county types defined by county poverty status and county-level trajectories of growth in GDP per capita. U5MR data have been adjusted for county-level underreporting, and all other data were obtained from administrative and official sources.ResultsThe U5MR dropped by 36.19% during the study period. One additional health professional per 1000 population was associated with a 2.6% reduction in U5MR, after controlling for other covariates. County poverty status and GDP trajectories moderated this relationship: the U5MR reductions attributed to a one-unit increase in health professionals were 6.8% among poor counties, but only 1.1% among non-poor ones. These reductions were, respectively, 6.7%, 0.7%, and 4.3% in counties with initially low GDP that slowly increased, medium-level GDP that rose at a moderate pace, and high GDP that rose rapidly.ConclusionsThis study demonstrates that increased health professionals were associated with reductions in U5MR. The largest associati

BACKGROUND:Prior research suggests that undernutrition and enteric infections predispose children to stunted growth. Undernutrition and infections have been associated with limited access to healthy diets, lack of sanitation, and access barriers to healthcare - all associated with human rights. Stunting has also been documented to be a major determinant of subsequent obesity and non-communicable diseases. Short leg length relative to stature during adulthood seems to be a good proxy indicator tracking such barriers, and has been reported to be associated with adverse health effects during adulthood. Our objective was to examine the association between relative leg length (as measured by the leg length index, LLI) and measures of adiposity - based on body mass index (BMI) and waist circumference (WC) - in a population of recent Mexican immigrant women to the New York City Area. METHODS:The analysis was based on a cross-sectional survey of 200 Mexican immigrant women aged 18 to 70 years, whose data were collected between April and November 2008; although for purposes of the current study we restricted the sample to those aged 18 to 59 years. The dependent variables were BMI and WC, both transformed into categorical variables. The main independent variable was LLI, and other correlates were controlled for (i.e. age, education, having had children, characteristics of the community of origin, acculturation, chronic conditions, sedentary behaviors, access to fresh fruits and vegetables). Two probit models were estimated: the first one analyzed the effect of LLI on BMI categories and the second one estimated the effect of LLI on WC. RESULTS:The probit assessing the effect of LLI on overweight/obesity suggested that having a short LLI increased the probability of overweight/obesity by 21 percentage points. Results from the probit model estimating the effect of LLI on WC indicated that having a short LLI increased the probability of having abdominal adiposity by 39 percentag

Excessive alcohol consumption contributes significantly to premature mortality, injuries and morbidity, and a range of U.S. state policies have been shown to reduce these behaviors. Monitoring state alcohol policy environments is essential, but methodologically challenging given that new laws may be passed (or repealed) each year, resulting in considerable variation across states. Existing measures have not been made public or have only a single year available. We develop a new replicable measure, the state alcohol policy score, for each state and year 2004-2009, that captures the essential features of a state's evidence-based alcohol policies. We evaluate its similarity to two existing alcohol policy measures and validate it by replicating findings from a previous study that used one of those measures to assess its relationship with several binge drinking outcomes. Estimates of the association between one-year lagged state alcohol policy scores and state binge drinking outcomes, obtained from the 2005-2010 Behavioral Risk Factor Surveillance System surveys (n = 440,951, 2010), were produced using Generalized Linear Models that controlled for state and individual-level co-variates, with fixed effects for year and region. We find a 10-percentage point increase in the state alcohol policy score was associated with a 9% lower odds of binge drinking (aOR = 0.91, 95% CI 0.89, 0.92; N = 1,992,086), a result consistent for men, women and for most age and race subgroups. We find that gender gaps in binge drinking behaviors narrowed in states with higher state alcohol policy scores. These results were nearly identical to those found in other studies using different scores obtained with the aid of expert opinions. We conclude that the score developed here is a valid measure that can be readily updated for monitoring and evaluating the variation and impact of state alcohol policies and make available our state scores for the years of the study.

BackgroundLife expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.New research networkIn order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.ConclusionFurther research using this framework has considerable potential to advance effective policies to advance health and equity.

Background: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. New research network: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. Conclusion: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

BackgroundLife expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.New research networkIn order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.ConclusionFurther research using this framework has considerable potential to advance effective policies to advance health and equity.

Background: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. New research network: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. Conclusion: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

This study uses data from a nationally representative household survey (the 2013 National Health Survey, n = 62,986) to describe patterns of alcohol consumption and related behaviors among Brazilian adults. Analyses include descriptive and multivariable Poisson regression for self-reports in the past 30 days of: drinking any alcohol, binge drinking, binge drinking 4 or more times, and driving after drinking (DD); as well as age of alcohol consumption initiation. Results show that current drinking prevalence was 26%, with an average age of initiation of 18.7 years. Binge drinking was reported by 51% of drinkers, 43% of whom reported binge drinking 4 or more times. Drinking and driving was reported by nearly one quarter of those who drive a car/motorcycle. Current drinking was more likely among males, ages 25-34, single, urban, and those with more education. Binge drinking was more likely among males, older age groups, and people who started drinking before 18. Drinking and driving was higher among males, those with more education, and rural residents. Those who binge-drink were nearly 70% more likely to report DD. All behaviors varied significantly among Brazilian states. Given their potential health consequences, the levels of injurious alcohol behaviors observed here warrant increased attention from Brazilian policymakers and civil society.