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Background The postpartum period is a critical transition period when exposures to protective factors such as breastfeeding can have long-lasting health impact. Studies have suggested downregulating effects of breastfeeding on stress biomarkers such as cortisol but have not explored the way breastfeeding interacts with allostatic load, a multisystem indicator of chronic stress. Objective We aimed to examine the association between breastfeeding and maternal allostatic load among women within 2 y postpartum using nationally representative data. Methods A cross-sectional analysis of 10 waves of data from the NHANES (1999-2018) was conducted in a sample of 1302 women aged ≥18 y who provided information on breastfeeding through the reproductive health questionnaire. Clinical and empirical allostatic load scores (range: 0-10; higher numbers associated with increased risk) were derived for each participant based on 10 biomarkers reflecting metabolic, cardiovascular, and immune health. Multiple linear regression tested associations between breastfeeding and allostatic load, adjusting for maternal age, race and ethnicity, education, poverty level, and survey wave. Results Breastfeeding had a significant inverse association with allostatic load in unadjusted and adjusted models. Controlling for age, race and ethnicity, education, poverty level, and survey wave, breastfeeding women had a 0.36-point lower clinical allostatic load score than nonbreastfeeding women (β = -0.36, SE = 0.11; 95% CI: -0.59, -0.14; P = 0.002) and a 0.44-point lower empirical allostatic load score (β = -0.44, SE = 0.15; 95% CI: -0.74, -0.14; P = 0.005). Conclusions Our study suggests that breastfeeding is protective of maternal stress and provides a more comprehensive picture of breastfeeding's influence on multiple body systems, exemplifying physiological benefits beyond effects on single biomarkers. However, limitations of cross-sectional data and non-classification of breastfeeding duration, mode, and intensity should be considered when interpreting these findings, and further research to address the role of breastfeeding and allostatic load is needed.

We evaluated children's cardiometabolic health (CMH) risk indicators and adverse childhood experiences (ACEs) stratified by family structure type (grandparent-headed, two-parent headed, and single-parent headed households). Separately, we assessed whether family structure type and number of ACEs were independently associated with the CMH risk indicators.Utilizing data from the 2017-2018 National Survey of Children's Health, we evaluated five CMH risk indicators (obesity, physical activity, secondhand smoke exposure, sleep, and sports participation). We used multivariable logistic regressions to assess the association of CMH risk indicators with family structure type and ACEs. We controlled for sex, age, race/ethnicity, health insurance, household poverty level, and overall health status.Among children aged 10-17 years (n = 24,885), we found the number of ACEs differed by family structure type (P 0.001) and was independently associated with obesity, secondhand smoke exposure, sleep, and sports participation. Adjusting for all covariates except ACEs, family structure type was significantly associated with children's CMH risk; but after controlling for ACEs that association was attenuated - except for sleep (less adequate sleep in grandparent-headed households) and exposure to secondhand smoke (less exposure in single-parent headed households).ACEs were highest among children living in grandparent-headed households and independently associated with a majority of the CMH risk indicators. Findings suggest that children living in grandparent-headed households may be at elevated risk for poor CMH, potentially due to higher risk for ACEs.It is recommended to consider ACEs and family structure type when assessing CMH risk in children.

Objectives To characterize patient and counselor satisfaction with structured, tier-based contraceptive counseling provided by a nonclinician. Study Design We conducted a planned secondary analysis of patient and counselor surveys from a study that enrolled women in 2 contraceptive care programs. All participants received structured contraceptive counseling from trained staff members. Women and counselors completed a confidential post-visit survey regarding satisfaction with counseling and medical mistrust. We used univariate and multivariable regressions to examine differences in high satisfaction with counseling (top score), perceived counselor influence, and perceived counselor judgment by participant characteristics. Results Nine hundred forty-two participants completed surveys; most reported they felt respected (100.0%), trusted the counseling information (99.5%), and that counseling helped them choose a contraceptive method (83.8%). Black race, high school education, public insurance, an income below the federal poverty level, and enrollment site were associated with high medical mistrust. Participants with high medical mistrust were less likely to be highly satisfied with counseling (adjusted relative risk (RR) 0.72; 95% confidence interval [CI] 0.63–0.82), more likely to perceive influence (RR 1.77; 95% CI 1.37–2.28), and more likely to perceive judgment (adjusted odds ratio 8.91; 95% CI 3.61–22.01). Mostly, counselors felt they were able to answer participant questions (98.8%), establish good rapport (95.9%), and that participants understood the information presented (98.0%). Conclusions Overall, participants were satisfied with tier-based contraceptive counseling delivered by nonclinician staff members. Those with high levels of medical mistrust were less likely to be satisfied. The majority of women found the information beneficial in contraceptive decision making. Implications Overall, women reported high satisfaction with tier-based contraceptive counseling delivered by a nonclinician in 3 federally qualified health centers. However, women with high medical mistrust were less likely to report high levels of satisfaction and more likely to report perceived influence or judgment from the counselor.

Purpose The purpose of the study was to evaluate the effects of early Medicaid expansions on young adults, who also benefitted from a private dependent coverage expansion. Methods We used the American Community Survey 2008–2013 to study three early expansion states—California, Connecticut, and Minnesota—using difference-in-differences. Control states are weighted combinations of other states and are similar to expansion states in the prepolicy periods. We analyze young adults and subgroups of women and men. Results Early Medicaid reduced uninsurance and improved public coverage among low- and moderate-income young adults beyond the private dependent coverage expansion, but results differed across states. California, which targeted up to 200 percent of the federal poverty level (FPL), reduced uninsurance 1.3 percentage points (4.2% relative to mean) and increased public insurance by 1.4 percentage points (14.0%). Connecticut, which targeted up to 56 percent of FPL, had no change to uninsurance but a 5.4 percentage point (42.5%) increase in public coverage. Minnesota's programs (up to 75 and 250 percent of FPL) produced a 4.2 percentage point (21.9%) decline in uninsurance for their lowest income group, but no measurable changes for their moderate-income group. Young men benefitted more than women. Their uninsurance declined as much as 6.0 percentage points (25.0%, in Minnesota) and their public coverage increased up to 9.1 percentage points (61.5%, in Connecticut). Conclusions Medicaid expansion benefits young adults, even those with moderate incomes, and even following a private dependent expansion. Results were larger and concentrated among young men, who historically had little engagement with the program.

Background Traumatic experiences often give rise to an increased risk of anxiety problems in adolescents. This study investigated the anxiety prevalence in adolescent earthquake survivors and the effect of secondary stressors such as bullying, poverty, or being “left behind” by parents working in the cities. Methods This cross-sectional study was conducted three years after the 2013 Ya'an (China) earthquake on 6,132 adolescents aged 9 to 18 years from 11 public schools in three severely earthquake affected counties. The participants completed self-report questionnaires that assessed anxiety, earthquake exposure, poverty level, left-behind duration and bullying. Results Separation anxiety (38.7%) and panic symptoms (32.2%) were found to be the primary contributors to anxiety in this adolescent sample. The regression and structural equation modeling indicated that adolescents who had suffered from high earthquake exposure, peer bullying, being left-behind, or poverty were more likely to report problems in all anxiety subcategories, with females reporting more anxiety symptoms than males. The likelihood of all anxiety disorders except separation anxiety was found to increase with age. Conclusions This study highlighted the need for post-disaster interventions aimed at minimizing post-earthquake adversity such as peer bullying and specialized psychological services that target subgroups that might be more susceptible to anxiety-related emotional problems. The results could be used to identify possible markers for anxiety problems in children who had not experienced any major traumas.

In March 2010, the Patient Protection and Affordable Care Act (ACA) was passed in the United States. Among other reforms, Medicaid expansion for low-income adults earning up to 138% of the federal poverty level contributed to broadening health insurance access to >17 million Americans ([1][1]).

Studies show that outdoor advertisements for unhealthy, consumable products are associated with increased intake and often target youth, low-income neighborhoods, and neighborhoods of color. Despite evidence that overconsumption of sugary drinks contributes to obesity and other chronic conditions, little is known specifically regarding the patterns of outdoor sugary drink advertising.The number of outdoor, street-level advertisements featuring sugary drinks was assessed in a random sample of retail-dense street segments (N=953) in low, medium, and high-poverty neighborhoods in each of New York City's 5 boroughs in 2015. Negative binomial regression was used to determine associations between sugary drink ad density, poverty level, and other census tract-level demographics (2009-2013 estimates) in each borough and New York City overall. Data were analyzed in 2017-2019.In New York City and in 3 of 5 boroughs, sugary drink ad density was positively associated with increased percentages of black, non-Latino residents (New York City: incidence rate ratio=1.20, p0.001; Bronx: incidence rate ratio=1.30, p=0.005; Brooklyn: incidence rate ratio=1.18, p0.001; Manhattan: incidence rate ratio=1.20, p0.05). Positive associations were also observed with poverty level in Brooklyn (low versus medium poverty: incidence rate ratio=2.16, p=0.09; low versus high poverty: incidence rate ratio=2.17, p=0.02) and Staten Island (low versus medium poverty: incidence rate ratio=3.27, p=0.03).This study found a consistent positive association between the density of outdoor sugary drink advertisements and the presence of non-Latino black residents in New York City and, in some boroughs, evidence of a positive association with neighborhood poverty. These findings highlight the inequities where sugary drinks are advertised in New York City.

Objective To investigate the existence and trajectory of diet disparities among college students from different socioeconomic statuses (SESs). Methods A random sample of freshman and sophomore students was invited to participate in an online survey on eating behaviors. Ordinary least squares regressions were fit to 148 complete responses to examine the association between family income ≤200% of the federal poverty level and overall, healthy, and unhealthy food consumption. Results Low-SES students reported eating significantly more unhealthy food during their freshman year than their non–low-SES peers. This difference is not statistically significant for second-year students and robust to on-campus spending power. Conclusions and Implications Disparities in diets for students from different socioeconomic backgrounds that were observed in the freshman year of college were absent in the sophomore year. Awareness of these disparities and trend is important to broadly promote healthy eating.

This article examines the effects of the Medicaid expansion on low-income, childless household savings. I exploit the structural changes in the Medicaid program by the Affordable Care Act, which extended the coverage to childless households and eliminated the asset-test for its eligibility. Analyzing the March Current Population Survey Supplement data, I find that the Medicaid expansion increased unearned income generated from savings for childless households with income below the 100% federal poverty level. However, the Medicaid expansion had no effects on earned or total income for those households.

Aims Electroconvulsive Therapy (ECT) is a well-established and effective treatment in mood disorders but the use of ECT in Texas is much lower than the general average among the United States. Our goal is to explore the geographical accessibility of Electroconvulsive Services in Texas. Methods 22 ECT Centers in Texas listed in State's 2016 annual ECT report were enrolled and georeferenced. We used Esri's StreetMap Premium Network release 1 network dataset to generate 1-hour drive time service areas for these ECTs. We estimated populations within these service areas based on US Census Tract level population-weighted centroids; generated from the 2015, American Community Survey (ACS) estimates at the US Census Block Group level. Results About 75% (19,851,802 of 26,538,614) of Texas total population is within a 1-hour drive time to any ECT Services location. When focusing on population below the poverty level from 2015 Block Group level ACS data: 68% (3,046,141 of 4,472,451) are within a 1-hour drive time. Conclusions ECT services are geographically accessible in Texas. Other barriers may contribute to lower use of ECT.

Under the Affordable Care Act, eligibility for Medicaid coverage was expanded to all adults with incomes up to 138% of the federal poverty level in states that participated. We sought to examine the national impact Medicaid expansion has had on insurance coverage for patients undergoing emergency general surgery (EGS) and the cost burden to patients.The National Inpatient Sample (NIS) was used to identify adults ≥18 y old who underwent the 10 most burdensome EGS operations (defined as a combination of frequency, cost, and morbidity). Distribution of insurance type before and after Medicaid expansion and charges to uninsured patients was evaluated. Weighted averages were used to produce nationally representative estimates.A total of 6,847,169 patients were included. The percentage of uninsured EGS patients changed from 9.4% the year before Medicaid expansion to 7.0% after (P 0.01), whereas the percentage of patients on Medicaid increased from 16.4% to 19.4% (P 0.01). The cumulative charges to uninsured patients for EGS decreased from $1590 million before expansion to $1211 million after.In the first year of Medicaid expansion, the number of uninsured EGS patients dropped by 2.4%. The cost burden to uninsured EGS patients decreased by over $300 million.

By using nationally representative consumer expenditure surveys of three quinquennial rounds conducted by NSSO, authors have measured the health expenditure induced removable poverty in the form of ‘hidden’ and ‘reinforced’ poverty in India. The analysis shows that both the incidence and depth of poverty are substantially understated because of overlooking out-of-pocket (OOP) health expenditure in the country's standard measure of poverty. It is the outpatient care that contributes most to the health expenditure impoverishment of the households in India. Muslims, among all religious groups, Scheduled Castes among social groups, and casual laborers among different household groups are more vulnerable to OOP health expenditure induced removable poverty in India. Poverty, in general, has dropped significantly, but the share of health expenditure induced poverty in general poverty has increased substantially, especially in rural India in the past 20 years. Health insurance coverage can make a significant change in the country's poverty level but focus on a particular group of the population may not solve this problem because health expenditure induced poverty is not any group-specific.

Background Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is associated with lower breastfeeding rates, compared to similar income non-participants. Breastfeeding decisions are often made before birth hence; the prenatal period may be critical for breastfeeding support. Objective To explore whether timing of WIC enrollment has an effect on breastfeeding exclusivity at 3, 5, and 7 months. As there are racial/ethnic disparities in breastfeeding, the association of timing of enrollment and race/ethnicity with breastfeeding outcomes was also assessed. Study Design, Setting, Participants This is a secondary analysis of data collected from the WIC Infant Toddler Feeding Practices Study-2, the most recent longitudinal assessment of mother-child dyads participating in WIC nationally. Only data collected from the prenatal through 7-months post-partum were included. Measurable Outcome/Analysis Logistic regression models analyzed the association between the timing of WIC enrollment - categorized as prenatal (1st, 2nd or 3rd trimester) or post-partum and exclusive breastfeeding - defined as being fed “only breastmilk” at each time point. Covariates included race/ethnicity, maternal age, education, parity, nativity, and poverty level. Results Prenatal WIC enrollment was associated with a 1.51 (95% CI: 1.08-2.17) and 1.37 (1.01-1.89) increased likelihood of exclusive breastfeeding at 5 and 7 months, respectively, as compared to post-partum enrollment. There were no significant differences at 3 months or by trimester of pregnancy. Mothers who were Hispanic and enrolled during the 2nd trimester had a 0.55 (0.33-0.91) decreased odds of breastfeeding at 3 months, with a similar trend observed (P = 0.062) during the third trimester for breastfeeding at 7 months. Conclusion Timing of WIC enrollment was associated with mother's infant feeding choice hence, supporting the prenatal period as an opportune time for breastfeeding education. A focus on prenatal breastfeeding education for Hispanic women who enroll during the 2nd trimester or later may be warranted.

Purpose To examine unmet health needs and health care utilization among youth with special health care needs (YSHCN). Methods We analyzed data among youth aged 12–17 years using the 2016 National Survey of Children's Health. We conducted descriptive analyses comparing YSHCN with non-YSHCN, and bivariate and multivariable analyses examining associations between dependent and independent measures. Six dependent variables represented unmet needs and utilization. Adjusted analyses controlled for sociodemographic and health measures. Results A total of 5,862 individuals were identified as YSHCN, and nearly 70% had three or more comorbid conditions. Over 90% used medical care, preventive care, or dental care in the past 12 months, while 8% reported having unmet health needs (compared with 2.8% of non-YSHCN). Using a typology of qualifying criteria for special health care needs, we found that YSHCN with increasing complexity of needs were more likely to report unmet health needs, use of mental health care services, and emergency department use, compared with YSHCN using medication only to manage their conditions. All YSHCN living in households below 400% federal poverty level were less likely to utilize nearly all types of health care examined, with the exception of mental health care use, compared with those at or above 400% federal poverty level. Conclusions Differences in complexity of needs, race/ethnicity, and poverty status highlight existing gaps in health care utilization and persistent unmet health needs among YSHCN. Efforts should focus on strengthening coordinated systems of care that optimally meet the needs of YSHCN so they may thrive in their families and communities.

Do customer-facing retail employees in the US have a higher prevalence of psychological distress? We examine psychological distress in a sample that includes 19,832 customer-facing retail employees from a sample of 1,115,280 employees of a cross-sectional National Health Interview Survey (NHIS) from 1997 through 2015. Our results show that customer-facing retail employees report significantly higher psychological distress than do employees in other industries and that its prevalence is increasing. These findings are consistent with mild and high levels of psychological distress. LASSO regression shows that, after self-reported health and poverty level, being a customer-facing retail employee is the third most important predictor of psychological distress.

INTRODUCTION: Cigarette smoking is substantially more prevalent and rates of smoking cessation are lower in low-SES adults. Financial strain may be one explanation for this. This study assessed the association between financial strain, quit attempts, and successful smoking cessation among adult smokers in the U.S. METHODS: Longitudinal data on adult current smokers (aged ≥18 years) from Waves 1 and 2 of the nationally representative Population Assessment of Tobacco and Health Study (2013–2015) were analyzed in 2017. Negative binomial regression and logistic regression models assessed the association between financial strain and (1) quit attempts and (2) cigarette abstinence, adjusting for important confounders. RESULTS: Smokers with financial strain made more quit attempts than smokers without financial strain (adjusted incidence-rate ratio=1.34, 95% CI=1.07, 1.68), but financial strain was not associated with smoking abstinence at follow-up (AOR=0.86, 95% CI=0.70, 1.05). Low income was associated with less smoking abstinence at follow-up (AOR=0.66, 95% CI=0.50, 0.87 for

Many colorectal cancer patients receive complex surgical care remotely. We hypothesized that their readmission rates would be adversely affected after accounting for differences in travel distance from primary/index hospital and correlate with mortality.We identified 48,481 colorectal cancer patients in the Surveillance, Epidemiology and End Results (SEER)-Medicare database. Travel distance was calculated, using Google Maps, and SAS. Multivariate negative binomial regression was used to identify factors associated with readmission rates. Overall survival was analyzed, using Kaplan-Meier and Cox proportional hazard.Thirty-day readmissions occurred in 14.9% of the cohort, 27.5% of which were to a nonindex hospital. In the colon and rectal cancer cohorts, readmissions were 14.5% and 16.5%, respectively. Rectal cancer patients had an increase in readmission by 13% (incidence rate ratios [IRR] 1.13; 95% confidence interval [CI] 1.05-1.21). Factors associated with readmission were male gender, advanced disease, length of stay (LOS), discharge disposition, hospital volume, Charlson score, and poverty level (P 0.05). Greater distance traveled increased the likelihood of readmission but did not affect mortality. Travel distance influences readmission rates but not mortality. Discharge readiness to decrease readmissions is essential for colorectal cancer patients discharged from index hospitals.

Balkan endemic nephropathy (BEN) is an irreversible, lethal kidney disease that occurs in regions of the Balkans where residents drink untreated well water. A key factor contributing to the development of BEN may be consumption of dissolved organic matter leached from low-rank coal called lignite. This hypothesis—known as lignite-water hypothesis—was first posed for areas of the Balkans. It is possible that a BEN-like condition exists in the United States (US) Gulf Coast region in parts of the Mississippi Embayment and the Texas Coastal Uplands aquifers —Arkansas, Louisiana, and Texas, for instance—that rely heavily on groundwater from aquifers that contain lignite. This study utilizes a geographic information system (GIS) to map the distributions of end-stage renal disease (ESRD) in relation to water from lignite-containing aquifers in the tri-state region. Regional patterns emerged from geospatial analysis, suggesting that counties that relied on lignite-containing aquifers for their main water source had higher rates of ESRD in comparison to other populations in the region that rely on other water sources, including surface water and groundwater from aquifers not associated with lignite seams. Statewide rates of ESRD and diabetes associated ESRD (ESRD-DM) showed strong correlations to the percent of families at or below poverty level and the percentage of African Americans. These confounding factors somewhat mitigate the association seen between ESRD and lignite-containing regions at the state level. However, at the larger tri-state view, there is a significant (p = 0.002) increase in incidence rates where groundwater is connected to lignite-containing aquifers when considering both race and poverty. Additionally, no relationship was observed between the rate of public water supply withdrawal from lignite-bearing aquifers and rates of ESRD or ESRD-DM at the state or tri-state regions, supporting the observation that the risk associated with water from lignite-containing aquifers is limited to water from untreated domestic supply.

Fires have important ecological and socioeconomic effects in fire-prone regions globally. Human-caused wildfires often pose considerable safety and environmental hazards, and can result in sizeable economic losses. This study analyzed the relative importance of temporal, spatial, and socioeconomic factors on occurrence of 52,532 human-caused wildfires in Mississippi that burned during 1991–2005. The probability of human-caused wildfires was modeled using a multinomial logit regression for unordered nominal outcomes. Results indicated that in comparison to incendiary wildfires, other types of human-caused wildfires were most likely to occur in summer. Wildfires caused by equipment use, children, and debris burning were more likely than incendiary wildfires to occur in close proximity to primary roads and railroad tracks, whereas close proximity to population centers increased the relative likelihood of wildfires caused by debris burning. Socioeconomic characteristics also influenced occurrence of many human-caused wildfires. Wildfires caused by children and debris burning were more likely than incendiary wildfires to occur in densely populated areas, whereas wildfires caused by debris burning, equipment use, and related to smoking were more likely in areas with high unemployment rates and large proportions of people below the poverty level. Wildfires related to smoking were also more likely than incendiary wildfires to occur in areas with higher median income. These findings will be helpful in predicting wildfire occurrence as well as developing new wildfire awareness and prevention strategies, allocating resources, and reducing wildfire damage costs in Mississippi and other fire-prone regions.

In the United States, the National School Breakfast (SBP) and School Lunch Program (NSLP) meals are provided for free or at a reduced price to eligible children, and are a nutrition safety net for low income children. Consuming both meals could provide 58% of daily intake. This paper evaluates the contribution of SBP and NSLP meals to the dietary intakes of 5–18 year old children participating in the National Health and Nutrition Examination Surveys (NHANES) from 2007 through 2012. The participants completed 24-hour dietary recalls. Least-square means and standard errors of the mean for energy and food group intakes for the total day and by school meal, and the percent of daily energy and food groups contributed by school meals were computed by analysis of covariance, with BMI, ethnicity, sex, age and poverty level as covariates. Of the 7800 participating children aged 5–18 years in the entire dataset, 448 consumed both SBP-NSLP meals on a weekday. Almost one-half (47%) of the day's energy intake was provided by the two school meals. For the major food groups, the contribution of school meals ranged from between 40.6% for vegetables to 77.1% for milk. Overall, these results provide important information on contribution of the SBP and NSLP meals to low income children's daily dietary intake., Highlights • School meals are a nutrition safety net for low income children. • We assessed the contribution of both meals to children's dietary intakes. • 47% of the day's calorie intake was provided by the two school meals. • School meals provided 41% of vegetables to 77% daily milk.

Tobacco minimum floor price laws (MFPLs) are a non-tax price policy that set a price below which tobacco products cannot be sold, thereby raising prices. Despite their growing interest among policy makers, little is known about the effects of local MFPLs on smoking prevalence or smoking intensity. We aimed to project the impact of a local tobacco MFPL on cigarette smoking prevalence and cigarette smoking intensity in Oakland, California, including detailed analysis of several important subpopulations. We used data collected between April 2017 and December 2019 from the California Behavioral Risk Factor Surveillance System and the National Youth Tobacco Survey to construct a static microsimulation model representative of Oakland. We projected the impact of MFPLs ranging from $8.00 to $13.00 per pack. All analyses were conducted between 2019 and 2020. With the introduction of an MFPL and assuming 15% policy evasion, mean price paid per pack was projected to increase by $1.05 to $4.69, cigarette smoking prevalence was projected to drop by 0.3% to 0.8%, and smoking intensity was projected to drop by 0.7% to 2.0% among continuing smokers. Total number of cigarettes smoked per month was projected to drop by 246,000 to 734,000 cigarettes, a 3.0% to 9.0% reduction from the current level (8.2 million cigarettes). The greatest reductions in cigarette smoking prevalence were among those aged 12 to 24-years-old, of non-Hispanic black or other race/ethnicity, and living below the federal poverty level. An MFPL in Oakland may substantially reduce cigarette use and target several important subpopulations.

The objective of this study was to provide recent temporal trends in parent-reported physical activity in children (6-11 years) between 2009 and 2014. Data from the 2009 to 2014 National Health and Nutrition Examination Survey were used. The analytic sample included 3946 children. Parent proxy of child physical activity at each of the 3 2-year cycles was assessed. For the entire sample, there was a quadratic trend, with the number of days children engaged in at least 60 min/d of physical activity increasing in the period 2011 to 2012 (6.12 days) when compared with the period 2009 to 2010 (5.96 days) and then decreasing in the period 2013 to 2014 (5.83 days). A similar quadratic trend was evident for boys, those above the poverty level, non-Hispanic whites (particularly boys), and those with less than the 85th body mass index-for-age percentile based on sex. A negative linear trend was observed for those above the poverty level and non-Hispanic whites (particularly girls). In conclusion, these findings provide suggestive evidence that over the past 6 years (1999-2014), parents report that children's physical activity has slightly decreased in the latest years, with this observation being most pronounced in boys, those above the poverty level, non-Hispanic whites, and those with less than the 85th body mass index-for-age and sex percentile. Encouragingly, however, across all evaluated subpopulations, most children (55%-82%), as determined by their parents, engaged in 60 min/d of physical activity (consistent with government recommendations).

We investigate whether taxpayers respond to a large, ACA-induced upward tax notch at the Federal Poverty Level. Using administrative tax data, we document bunching in the income distribution and provide estimates of the taxable income elasticity. Our estimates are the only ones using US data that are identified by panel variation in budget constraints rather than functional form assumptions (Blomquist and Newey 2017), a feature of our novel longitudinal estimator. Consistent with Saez (2010), we find bunching only among the self-employed. Analysis of linked tax and survey data suggests that bunching is likely not representative of changes in labor supply.

Introduction Prepared, ready-to-eat foods comprise a significant part of Americans' diets and are increasingly obtained from food stores. Yet, little is known about the availability and healthfulness of prepared, ready-to-eat food offerings at stores. This study examines associations among community characteristics (racial/ethnic composition, poverty level, urbanicity) and availability of both healthier and less-healthy prepared foods in U.S. supermarkets, grocery stores, and convenience stores. Methods Observational data were collected from 4,361 stores in 317 communities spanning 42 states in 2011 and 2012. Prepared food availability was assessed via one healthier food (salads or salad bar), three less-healthy items (pizza, hot dog/hamburger, taco/burrito/taquito), and one cold sandwich item. In 2014, multivariable generalized linear models were used to test associations with community characteristics. Results Overall, 63.6% of stores sold prepared foods, with 20.0% offering prepared salads and 36.4% offering at least one less-healthy item. Rural stores were 26% less likely to carry prepared salads (prevalence ratio [PR]=0.74, 95% CI=0.62, 0.88) and 14% more likely to carry at least one less-healthy prepared food item (PR=1.14, 95% CI=1.00, 1.30). Convenience stores in high-poverty communities were less likely to carry prepared salads than those in low-poverty communities (PR=0.64, 95% CI=0.47, 0.87). Among supermarkets, prepared salads were more likely to be carried in majority-white, low-poverty communities than in non-white, high-poverty communities. Conclusions Increasing the healthfulness of prepared foods within stores may offer an important opportunity to improve the food environment.

Objective To assess how many uninsured children are eligible for coverage through Medicaid or the Children's Health Insurance Program (CHIP) but not participating and examine the reasons low-income uninsured children are unenrolled. Methods Medicaid/CHIP eligibility and participation are estimated for a sample of over 1.4 million children in the 2008 and 2012 American Community Survey. Medicaid/CHIP experience and enrollment barriers are examined for 2300 uninsured children in families with incomes below 200% of the federal poverty level in the 2011–2012 National Survey of Children's Health. Results Despite increases in the number eligible for Medicaid or CHIP between 2008 and 2012, participation rose nationwide by 6 percentage points; by 2012, 21 states and the District of Columbia had participation rates for children of 90% or higher. The number of eligible but uninsured declined from 4.9 to 3.7 million, but 68% of uninsured children in 2012 qualified for Medicaid or CHIP. Interest in enrolling uninsured children in Medicaid or CHIP is high (more than 90% of parents say they would enroll their child), but despite the high rates of prior enrollment, many families had knowledge gaps and perceived difficulties with enrollment. Conclusions Addressing enrollment/retention barriers and raising Medicaid/CHIP participation in low-performing states hold promise for reducing the number of eligible but uninsured children given the diverse set of states with high participation and the high expressed interest in enrolling children.

Disabled individuals under 65 years old account for 15% of Medicaid recipients but half of all Medicaid spending. Despite their large cost, few studies have investigated the effects of Medicaid expansions for disabled individuals on insurance coverage and crowd-out of private insurance. Using an eligibility expansion that allowed states to provide Medicaid to disabled individuals with incomes less than 100% of the federal poverty level, I address these issues. Crowd-out estimates range from 49% using an ordinary least squares procedure to 100% using two-stage least-squares analysis. This potentially large degree of crowd-out could have fiscal implications for the Affordable Care Act which has greatly expanded Medicaid eligibility in 2014.

The article covers main reasons of emerging a new type of economy, the “green” economy. The aims and objectives of developing green economy were analyzed. The significance of an economy reform carried out on both national and global levels was evaluated. We analyzed both speed and level of the green economy development in the world and in the most developed countries of the world. An influence of institutional and investment factors on the process of greening economy was studied. The authors evaluated an influence of scientific and technical researches on transition of economy to its new model. An influence of leading countries, economical global leaders, on greening interstate and global economy was reviewed and analyzed. Possible perspectives of the global green economy development and consequences of greening process are given. The article determines factors that influence on the level of economic and social prosperity and welfare of society. The authors show negative consequences of the existing economic model that influence the society level of living, poverty, prosperity and welfare. It is proved by Japan experience that contributions into development of “green” economy sectors and R&D works promote greening food, influence welfare of society and life expectancy. A conclusion was made that transition to green economy will favorably influence health level of any nation and increase factors that promote development of social and economic prosperity and welfare of society in general.

This article examines the effects of the Medicaid expansion on household financial income by focusing on the Affordable Care Act. The Affordable Care Act extended Medicaid program to childless adults and eliminated the asset-test for its eligibility from 2014. Using the March Current Population Survey Supplement Data, I find that households with no dependent children and income below the 100% federal poverty level living in Medicaid-expansion states significantly increased the annual dividend (interest) income by 63 (84) dollars after the Medicaid expansion. Meanwhile, the financial assistance these households received from relatives or friends was reduced by 159 dollars after the expansion.

Despite real wages weak growth since August 2016, real disposable cash incomes are contracting and material situation is getting worse. In 2016, the poverty level increased compared to 2015 and came to 13.5% which is above the poverty level of 2007–2015.

Objective To examine how receiving or being denied a wanted abortion affects the subsequent development, health, caregiving, and socioeconomics of women's existing children at time of seeking abortion. Study design The Turnaway Study is a 5-year longitudinal study with a quasi-experimental design. Women were recruited from January 2008 to December 2010 from 30 abortion facilities throughout the US. We interviewed women regarding the health and development of their living children via telephone 1 week after seeking an abortion and semiannually for 5 years. We compare the youngest existing children younger than the age 5 years of women denied abortion because they presented for care beyond a facility's gestational limit (Turnaway group) with those of women who received the abortion (Abortion group). We used mixed-effects regression models to test for differences in outcomes of existing children of women in the Turnaway group (n = 55 children) compared with existing children of women in the Abortion group (n = 293 children). Results From 6 months to 4.5 years after their mothers sought abortions, existing children of women denied abortions had lower mean child development scores (adjusted β −0.04, 95% CI −0.07 to −0.00) and were more likely to live below the Federal Poverty Level (aOR 3.74, 95% CI 1.59-8.79) than the children of women who received a wanted abortion. There were no significant differences in child health or time spent with a caregiver other than the mother. Conclusions Denying women a wanted abortion may have negative developmental and socioeconomic consequences for their existing children.

Background Little research has investigated women's interest in and factors associated with viewing their ultrasound image in abortion care. Study Design Using medical records for all abortion care visits in 2011 ( n =15,575) at an urban abortion provider, we determined the proportion of women who chose to view by sociodemographic and pregnancy-related characteristics. We used bivariate and multivariable mixed-effects logistic regression models to examine associations between individual-level factors and the decision to view. Results A total of 42.6% of women chose to view. Identifying as nonwhite, being under age 25, being at or below the federal poverty level, and having medium or low decision certainty about the abortion were associated with increased odds of viewing. Being age 30 and over, having previously been pregnant and being more than 9 weeks gestation were associated with decreased odds of viewing. Conclusions Many women seeking abortion care want to view their ultrasound image when offered the opportunity.

D entistry is in the midst of a major transition. One key driver of change is the Affordable Care Act (ACA), which has many provisions relevant to the dental care sector. A key provision of the ACA is Medicaid expansion, which has the potential to reshape the dental benefits landscape considerably. Let’s first look at trends in Medicaid before ACA. For more than a decade, public health insurance coverage for children was growing steadily with the expansion of Medicaid and the Children’s Health Insurance Program (CHIP). Because dental benefits for children are mandatory under Medicaid and CHIP, this trend altered the dental benefits landscape considerably. In 2000, 20% of US children had dental benefits through Medicaid and CHIP, 58% had dental benefits through private dental plans, and 22% had no dental benefits. By 2012, the percentage of US children with dental benefits through Medicaid and CHIP increased to 37%, whereas the percentage with private dental benefits decreased to 50%; the percentage with no form of dental benefits decreased andwas cut almost in half to 13%.When it comes to children, Medicaid is no longer a low-income-only program, and income eligibility in most states is many times the federal poverty level. For adults, on the other hand, the pre-ACA trends have been different. Adult dental benefits are

Indigenous people, who rely on traditional economic system focusing on self-sufficiency and dependency on forest resources for survival, are living at poverty level. Tourism products can be developed through nature and the cultures of indigenous people. The study was conducted among indigenous people to identify the factors that attracted them to be involved in tourism activities. The findings showed that indigenous people are willing to engage in tourism activities. Based on these findings, the researcher carried out ideas using Vocational Education (Tourism) through Pro-Poor Tourism Approach (PPT) to eradicate poverty among the indigenous people communities.

This study estimates the prevalence of households raising more than one child with disabilities, and examines these families' economic well-being. Using pooled data from the 2004 and 2008 Survey of Income and Program Participation we compare households with multiple children with disabilities (n = 932) to households with one disable child (n = 3457) and to households with at least one child but none with disabilities (n = 21,378) on measures of material hardship. Three percent of U.S. households with children had more than one disabled child. Compared to other households with children, those with multiple children with disabilities were significantly more likely to have income below the federal poverty level and to report material hardships. The number of children with disabilities is an important contextual variable for studying the economic circumstances under which, care is provided to children with disabilities. Its implications for practice and policy are discussed.

Introduction Childhood obesity and dental caries are increasing epidemics, especially among children who are living below the poverty level. This study was conducted to determine the relationship between body mass index (BMI) and caries in homeless children. Methods A secondary data analysis with a correlational design was used. A convenience sample of 157 children was recruited from a homeless shelter. Results Pearson’s and partial correlations were used to explore the relationships among age, BMI, and caries. Most of the children were girls and were African American. Slightly more than half of the children were overweight (19.7%) or obese (30.6%) and had caries (50.3%). Significant positive correlations between age and BMI ( p = .03) as well as between age and caries ( p = .003) were found. As BMI increased, so did caries ( p = .08). Discussion Consistent with reports from the Centers for Disease Control and Prevention, homeless children had higher BMI and caries rates than the national averages. Although a definitive conclusion between obesity and dental caries cannot be drawn, these two health issues are important areas for all pediatric health care providers to address at every visit.

The paper presents a historical research of the demographic development of Kazakhstan for the last hundred years, which is divided into six stages, and reveals the characteristic features of each stage with respect to the indigenous nation. We conducted the correlation analysis to determine causal relationships of the birth rate per thousand people with such factors as employed male population, proportion of the population below the poverty level, average men's salary, housing per person. Consequently, the main problems of demographic development were identified, and recommendations to improve the demographic situation of the country were provided. Thus, economic mechanisms to address and solve demographic problems of Kazakhstan were considered for the first time.

Azerbaijani Abstract: Məqalədə yoxsulluq səviyyəsi, yoxsullugun yaranmasina səbəb olan amillər, yoxsullugun azaldilmasi istiqamətində qəbul olunan dovlət proqramlarinin əhəmiyyəti nəzərdən kecirilmis, eləcə də yoxsulluq səviyyəsinə ev təsərrufatlarinin ailə tərkibinin təsiri arasdirilmisdir. Eyni zamanda, Avropa Yenidənqurma və Inkisaf Bankinin, Dunya Bankinin və digər nufuzlu beynəlxalq təskilatlarin hesabatlarinda da olkəmizdə insan inkisafi, yoxsullugun azaldilmasi sahəsində irəliləyislər oldugu, əhalinin yoxsul təbəqələrinin həyat səviyyəsini nisbətən yaxsilasdirmagin mumkunluyu məqalədə qeyd olunmusdur. English Abstract: In this article standards of poverty, all factors that caused to poverty, mitigation of poverty that has been accepted in terms of government programs has been looked through, as well as, the impact of family structures of household economy to poverty level has been researched. Meanwhile, European Bank for Reconstruction and Development, World Bank and other international organizations reports about human development that is increasing in our country, progresses of poverty mitigation and the possibility of improving welfare of the poor sections of the population have been mentioned in this article.

The Affordable Care Act expanded Medicaid eligibility to adults who are below 138 percent of the federal poverty level. There is little to no evidence on the employment effects of the Medicaid expansion in 2014. This paper investigates the pre/post labor market implications of Medicaid expansion with a population near the eligibility cutoff. Using an exogenous variation at the eligibility cutoff, I find a large reduction in part-time employment (

Diabetes is a complex disease, and patients face barriers to reaching glycosylated hemoglobin (HgbA1c) goals. A retrospective cohort chart review evaluated if the cost of diabetes medications is a barrier to glycemic goals in uninsured patients receiving reduced-cost medications. Thirty-five patients were followed over 6 months to determine the association between HgbA1c and medication possession, monthly income, drug costs/month/patient, and poverty level. Higher HgbA1c was associated with higher drug cost/month ( P = 0.005), but better medication possession was not associated with lower HgbA1c levels. Providers should tailor care to address factors (other than cost) known to influence HgbA1c.

This paper presents an axiomatic framework for measuring life time poverty over multiple periods. For an individual, we argue that lifetime poverty is influenced by both the snapshot poverty of each period and the poverty level of the "permanent" lifetime consumption; it is also influenced by how poverty spells are distributed over the life time. Two obvious candidates for aggregation are to aggregate over time and then across individuals, or vice versa. For a society, we consider a path-independence requirement to make these two approaches of aggregation consistent. We axiomatically characterize classes of lifetime poverty indices and derive dominance conditions of poverty orderings for both individual and societal lifetime poverty measurements.

Background Exposure to secondhand smoke (SHS) is a contributor to the increased morbidity and mortality experienced by inner-city African-American children. Limited evidence-based programming exists regarding how to address the negative effects of SHS in this community. Purpose A collaboration with an early child care center provided an opportunity to explore factors related to young children's SHS exposure as the first step in developing strategies to reduce exposure. Methods Survey data were obtained between 2008 and 2009 from 63 African-American parents of infants and children aged ≤5 years at two early child care centers located in an urban Minneapolis neighborhood. Forty-three of these children had salivary cotinine levels assessed. Results Parents living below the poverty level were more likely to report that their children were regularly exposed to SHS by family/friends (p=0.01). Sixty-eight percent of participants reported complete home smoking restrictions, which was significantly correlated with advice from the child's health provider (p=0.001). Nonsmokers and older parents were less likely to receive advice (p=0.03). Of the 43 children in whom cotinine levels were assessed, 39.5% had levels >0.64 ng/ml, which suggests high SHS exposure. Lower cotinine levels were significantly correlated with living in detached houses. Conclusions Exposure to SHS was common for children in this study. These findings, if supported by additional research, can be used to develop and disseminate targeted health messages about childhood SHS sources/negative effects and strategies to reduce exposure.

More than 2.4 million grandparents in the United States provide primary care for more than 4.5 million grandchildren, but little is known about how grandparents in the child welfare system (CWS) parent their grandchildren. Using a nationally representative sample of children reported for maltreatment to the CWS, the authors compared the parenting and home environments provided by grandmothers with those provided by nonkin foster caregivers. Grandmothers were older, less educated, less likely to be married, and more likely to be subsisting beneath the federal poverty level than foster caregivers. Grandmothers had significantly better parenting scores than foster caregivers, even when the child's age and the caregiver's race/ethnicity, education, and poverty level were taken into account. The home environment provided by grandmothers in the CWS was generally as good as the one provided by foster caregivers. These findings suggest that grandmothers are striving to give affection, be responsive, and—within their economic means—provide learning opportunities for the child. Findings also yield a profile of grandmothers' social and economic disadvantages, suggesting the need for increased support for grandmothers caring for children in the CWS.

Data from the 2002 National Survey of Children with Special Health Care Needs were analyzed to understand the state-level policies and individual characteristics associated with receipt of professional care coordination by families raising children with special health care needs. Families living in states with more generous State Children's Health Insurance Programs (SCHIP) were more likely to receive professional care coordination. Numerous individual characteristics are associated with receipt of support services. States could likely improve access to support services for these families by expanding SCHIP and implementing targeted measures to help uninsured children, children whose parents do not speak English, those living below 300% of the federal poverty level, and families raising children with the most severe impairments.

Information about folate intake among low-income women of childbearing age remains limited. This report presents results from a cross-sectional study of folate intake and food-related behaviors in a sample of low-income, nonpregnant women of childbearing age in California. One hundred fifty-seven nonpregnant, low-income (≤185% federal poverty level) women of childbearing age (18 to 45 years) were evaluated for usual intake of natural food folate and synthetic folic acid, as well as specific food-related behaviors. Eighty-five percent of participants met the Recommended Dietary Allowance for folate, but only 37% met the current synthetic folic acid recommendation for reducing the risk of neural tube defects. Intake of naturally occurring food folate and intake of synthetic folic acid from supplements were positively associated with overall healthful food-related behaviors. Nutrition education that includes information about folic acid may be one way to improve folate intake and other healthful food behaviors among low-income women of childbearing age.

Purpose Little is known about use and expenditure patterns of children’s eye-care services and about possible disparities in care among children. This report describes the use and expenditure patterns of eye care and non–eye care services for children under 18 years old in the United States. Methods Levels of use and expenditure were estimated using self-reported information from the nationally representative Medical Expenditure Panel Surveys (1996-2001) for 48,304 subjects under 18 years old from randomly selected households in the United States. Means presented for children with and without diagnosed eye conditions were adjusted for child and family characteristics using generalized linear models. Results Children with diagnosed eye conditions had higher levels of use and expenditure than children without diagnosed conditions. Families of children with diagnosed eye conditions incurred higher out-of-pocket expenditures. Black children and children living below 400% of the federal poverty level had lower levels of use and expenditure, indicating that they received fewer and less intensive services. Conclusions Children with diagnosed eye conditions experienced higher overall use of health care. Some groups of children appear to be underserved. Estimates of use and expenditure patterns, stratified by socioeconomic factors, will be needed to plan for future delivery of children’s eye and vision care services and to assess progress toward Healthy People 2010 goals.

New York City’s recycling program began in 1988 with scattered pilot programs to collect a restricted number of recyclable categories. Over time, the program was made more uniform in its implementation, was expanded citywide, and targeted more types of recyclables. Although Department of Sanitation surveys have shown that residents in all areas of the city have understood the requirements of the recycling program, recycling diversion rates vary substantially throughout the city’s neighborhoods, ranging from 9 to 31% per district, while city-wide the diversion rate averages only about 20%. This paper explores the possible reasons for the disparity of recycling participation rates amongst neighborhoods, using recycling data collected by the city and federal census information to characterize the city’s neighborhoods and show variation in recycling participation rates, demographics, socio-economic indicators, and other metrics. Four variables were found to be strongly correlated with low diversion rates: percentage of persons below poverty level; percentage of households headed by a single female with children; percentage of adults without a high school diploma; and percentage of minority population.

Surveys carried out in mountainous areas of northern Vietnam at research sites selected across a gradient of market integration, revealed strong relationships between the location of the village with respect to the national road network and the nature of its land-use systems, its poverty level and more generally its potential for development. We developed and tested in Bac Kan province a method to give an objective and quantitative definition of accessibility over a large geographic area. Accessibility maps integrated in a provincial GIS showed that despite recent improvements to the road network, some remote areas do not benefit from recent development.

With the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Medicaid eligibility ceased to be tied to receipt of cash assistance. Since then, states have had a growing number of opportunities to expand health coverage to low-income working families beyond previous AFDC limits. As of 2001, 20 states have raised income eligibility limits for parents to or beyond 100% of the Federal Poverty Level. First, we use the Current Population Survey to study the effect of states' expansions on the insurance rates of adults and to estimate the crowd-out of private insurance. We find that eligible adults living in a state that expanded coverage are more likely to be insured. We find a take-up rate of 14.8%. Our results suggest that 24% of this increase is due to a reduction in private coverage. Next, we use the Behavioral Risk Factor Surveillance System to examine changes in health care utilization. We find that these expansions increased cancer-screening rates. Of previously uninsured mothers not receiving cancer screening, 29% now receive these screens. Finally, our results indicate the expansions decreased the likelihood that a parent needed to see a doctor but did not because of cost.

People in developing countries currently consume on average one-third the meat and one-quarter of the milk products per capita compared to the richer North, but this is changing rapidly. The amount of meat consumed in developing countries over the past has grown three times as much as it did in the developed countries. The Livestock Revolution is primarily driven by demand. Poor people everywhere are eating more animal products as their incomes rise above poverty level and as they become urbanized. By 2020, the share of developing countries in total world meat consumption will expand from 52% currently to 63%. By 2020, developing countries will consume 107 million metric tons (mmt) more meat and 177 mmt more milk than they did in 1996/1998, dwarfing developed-country increases of 19 mmt for meat and 32 mmt for milk. The projected increase in livestock production will require annual feed consumption of cereals to rise by nearly 300 mmt by 2020. Nonetheless, the inflation-adjusted prices of livestock and feed commodities are expected to fall marginally by 2020, compared to precipitous declines in the past 20 y. Structural change in the diets of billions of people is a primal force not easily reversed by governments. The incomes and nutrition of millions of rural poor in developing countries are improving. Yet in many cases these dietary changes also create serious environmental and health problems that require active policy involvement to prevent irreversible consequences.