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BACKGROUND HIV-related discrimination in health care settings is associated with negative health outcomes among persons with HIV (PWH). This article describes and compares differences in the prevalence of self-reported experiences with discrimination in health care settings by sociodemographic and clinical care factors among persons with diagnosed HIV in the United States. METHODS We analyzed interview and medical record data collected during June 2018-May 2019 from 3850 PWH who had received HIV care in the past 12 months. We calculated weighted percentages and associated 95% confidence intervals and assessed the association between any experience of discrimination and selected sociodemographic and clinical characteristics using prevalence ratios with predicted marginal means. RESULTS Approximately 25% of PWH who had an HIV care visit in the past 12 months reported experiencing any discrimination. Experiences with discrimination were significantly more prevalent among persons aged 18-29 years (34%); transgender persons (41%); persons of gay (25%), bisexual (31%), or other (40%) sexual orientations; and persons who did not have a regular provider (39%), lived at/below poverty level (28%), were homeless (39%) or incarcerated (37%) in the past 12 months. PWH who experienced discrimination were more likely to have missed at least one HIV care visit, not be taking antiretroviral therapy, and have missed antiretroviral therapy doses. Recent and sustained viral suppression were not significantly associated with experiencing any discrimination. CONCLUSIONS Interventions that address the sociocultural and structural factors associated with discrimination in all health care settings are needed to improve health outcomes among PWH and end the HIV epidemic in the United States.

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.

Objectives Trends in the incidence of precancerous cervical lesions can be monitored to evaluate the impact of human papillomavirus (HPV) vaccination. The objective of this analysis was to determine whether declines in precancerous cervical lesions varied by area-based measures of poverty, race, and ethnicity. Methods We analyzed 11 years of incidence data (2008-2018) from a statewide active surveillance system of precancerous cervical lesions in Connecticut. We divided area-based measures of poverty, race, and ethnicity (percentage of the population in a census tract who were living below the federal poverty level, who were Black, and who were Hispanic) at the census-tract level into 4 groups (Results During 2008-2018 in Connecticut, 18 878 women aged 21-39 were diagnosed with precancerous cervical lesions. After adjusting for screening, the largest declines occurred among women aged 21-24 (AAPC = −11.5%; 95% CI, −13.6% to −9.4%). We found significant and similar annual declines (~10%-12%) in this age group across all 4 levels of poverty, race, and ethnicity. Conclusions This analysis adds to the growing body of evidence demonstrating the positive impact of population-level HPV vaccination among young women that appears similar across area-based measures of sociodemographic characteristics. Monitoring is necessary to ensure the continuation of this progress in all communities.

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.

Background Medicaid expansion and subsidized private plans purchased on the Affordable Care Act’s (ACA) Marketplaces accounted for most of the ACA’s coverage gains. Objective Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans. Design Cross-sectional survey Participants A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases. Main Measures Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain. Key Results Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes. Conclusion Medicaid offers better protections than Marketplace plans on most measures of access and financial strain. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07100-0.

\This study was conducted with the aim of analyzing the effect of unemployment on the poverty level, the effect of the human development index (HDI) on the poverty level, gross domestic product (GDP) on the poverty level, and the effect of unemployment, HDI and GDP on the level of poverty. This study uses secondary data obtained from the Central Statistics Agency (BPS) and other related sources. Data were analyzed using the multiple linear regression model using SPSS 25 Application. The results of this study indicate that: (1) Unemployment has a positive and insignificant effect on the level of poverty; (2) Partially, the HDI and GDP have a negative and insignificant effect on the level of poverty; (3) Simultaneously Unemployment, HDI and GDP have a significant effect on the level of poverty. The results of this study indicate that in order to significantly reduce the Poverty Level in East Luwu, the three independent variables must be the attention of the East Luwu Government in making development policies. Increase the HDI mainly in terms of education and health to provide more competitive human resources, pursue high GDP growth level, and be more qualified and inclusive to reduce poverty levels in East Luwu.

Introduction Low-income populations have higher rates of smoking and are disproportionately affected by smoking-related illnesses. This study assessed the long-term impact of increased coverage for tobacco cessation through Medicaid expansion on past-year quit attempts and prevalence of cigarette smoking. Methods Using data from CDC's annual Behavioral Risk Factor Surveillance System 2011-2019, we conducted difference-in-difference regression analyses to compare changes in smoking prevalence and past-year quit attempts in expansion states versus non-expansion states. Our sample included non-pregnant adults (18-64 years old) without dependent children with incomes at or below 100% of the Federal Poverty Level (FPL). Results Regression analyses indicate that Medicaid expansion was associated with reduced smoking prevalence in the first two years post-expansion (β=-0.019, p=0.04), but that this effect was not maintained at longer follow-up periods (β=-0.006, p=0.49). Results of regression analyses also suggest that Medicaid expansion does not significantly impact quit attempts in the short-term (β=-0.013, p=0.52) or at longer term follow-up (β=-0.026, p=0.08). Conclusions Expanded coverage for tobacco cessation services through Medicaid alone may not be enough to increase quit-attempts or sustain a reduction in overall prevalence of smoking in newly eligible populations over time. Medicaid programs should consider additional strategies, such as public education campaigns and removal of barriers, to support cessation among enrollees.

Economic development in Indonesia is a process of building a complete human being, so that it can improve the community welfare. The main goal of economic development is poverty alleviation. The government through Nawacita is committed to developing Indonesia from the periphery, including by increasing development in villages. One of the government expenditures aimed at reducing poverty in rural areas is through financial assistance, namely the Village Fund. In addition to village funds, the quality of human resources also determines the poverty levels in each region. The quality of human resources includes the dimensions of one's education and health. The research objective was to analyze the effect of village funds and the quality of human resources on the poverty level and community welfare in the regencies/cities of Bali Province. The data used is panel data for regencies/cities in Bali Province in 2015 – 2019 obtained from the Central Statistics Agency for Bali Province, the Bali Province Community and Village Empowerment Service and the Directorate General of Fiscal Balance (DPJK)-Ministry of Finance of the Republic of Indonesia. The data analysis technique used in this study is descriptive statistics and path analysis. The results of the research analysis show that the village funds have no negative and insignificant effect on poverty levels. The quality of human resources has a negative and significant effect on the level of poverty. Village funds have no positive and insignificant effect on community welfare. The quality of human resources has a positive and significant impact on community welfare. The poverty levels have a negative and significant effect on community welfare. The Village funds indirectly have no significantly effect on community welfare through poverty levels. The quality of human resources indirectly has a significantly on community welfare through the poverty levels in the regencies/cities in the Province of Bali.

This paper measures the poverty level of resettlers in the floodplains of the downstream Yellow River before and after resettlement. The Shapley value decomposition method is used to measure the in...

One of the instrument trusted to decrease poverty is zakat especially if distributed to productive activities. This research aimed to find out if the distribution of productive zakat has effect on the decrease level of mustahik poverty, to find out total and classification of mustahik households and the change of mustahik households without and with productive zakat. This research used correlative quantitative method with analysis technique of simple linear regression and CIBEST analysis. This research used saturated sample technique to mustahik of Amil Zakat Board (BAZNAS) of Banjarmasin City with a total of 23 respondents. From the research results, it can be concluded that the distribution of productive zakat has no significant effect decreasing on the poverty level of mustahik. This can be seen from the t count (-1,177) < t table (2,079) and from F count (1,385) < F table (4,30) p value (Sig) in the amount of 0,252 > 0,05 which means that Ho is accepted. Based on total households of mustahik based on CIBEST quadrant before and after the presence of productive zakat fund, there is difference of classification of each mustahik household. The condition change of mustahik household without and with productive zakat fund based on material and absolute poverty index each experienced decrease in the amount of -10,5 and -100%. Spiritual poverty index does not change at all either before or after accepting productive zakat in the amount of zero percent. While prosperity index increase to 504,7%.

Background: In 2016, Sight for All United (SFAU) was founded in the Mahoning Valley of Ohio with the mission of improving access to care and maximizing the visual potential of the underserved. Methods: A retrospective chart review was conducted on patients served by SFAU from January 2016 through August 2020. Socioeconomic information, type of service, cost, and dollar amount paid were collected for patients. The data were analyzed with descriptive statistics and mapped with Esri ArcGIS. Results: A total of 1327 patients received assistance through the medical assistance and school vision programs. In the medical assistance program, 222 patients (mean age 50 years, 57% female) completed applications and 37% (83 patients) were in a household of 3 or more people. Median yearly income was $18 504, 134% above the federal poverty level by household size. The most common surgical services were cataract surgery (101) and vitreoretinal care (17). The most common medical services were eye exams (79) and spectacles (76). Estimated value of medical services provided was $367 249; actual cost was $93 746. The school vision program provided 1105 eye exams, 1514 pairs of spectacles, and 1 cataract surgery with an estimated value of $133 692. Conclusion: Sight for All United provided $500 941 of vision services to its patients since 2016 while dispersing less than $100 000 of donated dollars through collaboration with eye care providers, community resources, and national foun-dations. This study demonstrates the impact vision foundations managed by local eye care providers can have on the needs in their community in a cost-effective and efficient way.

Regencies/cities in the Province of Bali as one of the areas experiencing problems with the rate of economic growth, income disparities and the development of poverty levels are not evenly distributed between regions These problems can be influenced by several factors, such as the tourism sector and the quality of human resources. Research purpose is to analyze the influence of the tourism sector and the quality of human resources on economic growth, income disparities and poverty levels in regencies/cities in Bali Province. The data used is secondary data, namely regency/city panel data in the Province of Bali in 2010-2019 which was obtained from the Central Statistics Agency for the Province of Bali. The data is then analyzed by path analysis using Partial Least Square. The results of the analysis show that the tourism sector and the quality of human resources have a positive and significant effect on economic growth. The tourism sector and economic growth have a positive and significant effect on income disparities, but the quality of human resources has a negative and insignificant effect on income disparities. The tourism sector and economic growth have a negative and insignificant effect on the level of poverty and the quality of human resources has a negative but significant relationship to the level of poverty, while income disparity has a positive and significant effect on the level of poverty. The tourism sector indirectly has no significant effect on income disparities through economic growth, while the quality of human resources indirectly has a significant effect on income disparities through economic growth. The tourism sector and the quality of human resources indirectly have no significant effect on the level of poverty through economic growth and income disparities, while economic growth indirectly does not significantly affect the level of poverty through income disparities in regencies/cities in Bali Province.

This study aims: To investigate whether the Poverty Level Affects Provincial Tax Revenues in Indonesia, to test whether per capita income affects provincial tax revenue in Indonesia, to test whether the Audit Opinion with Intervention Variables, Public Trust Level, to test whether the Audit Opinion affects Provincial Tax Revenues in Indonesia. This academic study typically uses secondary data with time series data for the period 2010, 2012, 2014, 2016, and 2018. The data analysis technique typically uses the stimulus equation with the path analysis estimation technique. The Statistical Package for the Social Science application program (SPSS) version 23 is typically used to carefully help carefully analyze the data typically used in this study. The results showed that: The level of poverty has a significant effect on Provincial Tax Revenues in Indonesia, Per capita income has no significant impact on Provincial Tax Revenues in Indonesia, Audit Opinion with Intervening Variables Community Trust Level typically has a significant effect on Provincial Tax Revenues in Indonesia.

OBJECTIVE: To estimate the incremental associations between the implementation of expanded Medicaid eligibility and prerelease Medicaid enrollment assistance on Medicaid enrollment for recently incarcerated adults. DATA SOURCES/STUDY SETTING: Data include person‐level merged, longitudinal data from the Wisconsin Department of Corrections and the Wisconsin Medicaid program from 2013 to 2015. STUDY DESIGN: We use an interrupted time series design to estimate the association between each of two natural experiments and Medicaid enrollment for recently incarcerated adults. First, in April 2014 the Wisconsin Medicaid program expanded eligibility to include all adults with income at or below 100% of the federal poverty level. Second, in January 2015, the Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance at all state correctional facilities. DATA COLLECTION/EXTRACTION METHODS: We collected Medicaid enrollment, and state prison administrative and risk assessment data for all nonelderly adults incarcerated by the state who were released between January 2013 and December 2015. The full sample includes 24 235 individuals. Adults with a history of substance use comprise our secondary sample. This sample includes 12 877 individuals. The primary study outcome is Medicaid enrollment within the month of release. PRINCIPAL FINDINGS: Medicaid enrollment in the month of release from state prison grew from 8 percent of adults at baseline to 36 percent after the eligibility expansion (P‐value

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.

BACKGROUND: Evidence is limited as to whether the introduction of the Affordable Care Act (ACA)’s Medicaid expansions was associated with improvements in cardiovascular risk factors at the population level. OBJECTIVE: To examine the association between the ACA Medicaid expansions and changes in cardiovascular risk factors among low-income individuals during the first 3 years of the implementation of the ACA Medicaid expansions at the national level. DESIGN: A quasi-experimental difference-in-differences (DID) analysis to compare outcomes before (2005–2012) and after (2015–2016) the implementation of the ACA Medicaid expansions between individuals in states that expanded Medicaid and individuals in non-expansion states. PARTICIPANTS: A nationally representative sample of individuals aged 19–64 years with family incomes below 138% of the federal poverty level from the 2005–2016 National Health and Nutrition Examination Survey (NHANES). INTERVENTION: ACA Medicaid expansions. MAIN MEASURES: Cardiovascular risk factors included (1) systolic and diastolic blood pressure, (2) hemoglobin A1c (HbA1c) level, and (3) cholesterol levels (low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol). KEY RESULTS: A total of 9177 low-income individuals were included in our analysis. We found that the ACA Medicaid expansions were associated with a lower systolic blood pressure (DID estimate, − 3.03 mmHg; 95% CI, − 5.33 mmHg to − 0.73 mmHg; P = 0.01; P = 0.03 after adjustment for multiple comparisons) and lower HbA1c level (DID estimate, − 0.14 percentage points [pp]; 95% CI, − 0.24 pp to − 0.03 pp; P = 0.01; P = 0.03 after adjustment for multiple comparisons). We found no evidence that diastolic blood pressure and cholesterol levels changed following the ACA Medicaid expansions. CONCLUSION: Using the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in cardiovascular risk factors related to hypertension and diabetes during the first 3 years of implementation. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06417-6.

Within a medical home, primary care providers can identify needs, provide services, and coordinate care for children with heart conditions. Using parent-reported data from the 2016–2017 National Survey of Children’s Health, we examined receipt of preventive care in the last 12 months and having a medical home (care that is accessible, continuous, comprehensive, family-centred, coordinated, compassionate, and culturally effective) among US children aged 0–17 years with and without heart conditions. Using the marginal predictions approach to multivariable logistic regression, we examined associations between presence of a heart condition and receipt of preventive care and having a medical home. Among children with heart conditions, we evaluated associations between sociodemographic and health characteristics and receipt of preventive care and having a medical home. Of the 66,971 children included, 2.2% had heart conditions. Receipt of preventive care was reported for more children with heart conditions (91.0%) than without (82.7%) (adjusted prevalence ratio = 1.09, 95% confidence interval: 1.05–1.13). Less than half of children with heart conditions (48.2%) and without (49.5%) had a medical home (adjusted prevalence ratio = 1.02, 95% confidence interval: 0.91–1.14). For children with heart conditions, preventive care was slightly more common among younger children and less common among those with family incomes 200–399% of the federal poverty level. Having a medical home was less common among younger children, non-Hispanic “other” race, and those with ≥2 other health conditions. Most children with heart conditions received preventive care, but less than half had a medical home, with disparities by age, socioeconomic status, race, and concurrent health conditions. These findings highlight opportunities to improve care for children with heart conditions.

The article is devoted to the spatial dimension of poverty in Łódź. The analyses are based on the data of the Municipal Social Welfare Centre in Łódź, containing information on the distribution of benefit recipients, spatially aggregated to the level of quarters. The spatial variability of the poverty level was studied using the location index and the local Moran statistics (LISA). The results of the research made it possible to indicate a clear spatial pattern manifested in the form of an increased level of poverty in the centre of Łódź. A number of clusters were also distinguished, i.e. spatially correlated quarters with a high percentage of benefit recipients and the accompanying areas of high contrasts of the analysed phenomenon. Artykuł poświęcony jest przestrzennemu wymiarowi ubóstwa w Łodzi. Podstawą przeprowadzonych analiz są dane Miejskiego Ośrodka Pomocy Społecznej w Łodzi, zawierające informacje o rozmieszczeniu zasiłkobiorców, zagregowane przestrzennie do poziomu kwartałów. Zmienność przestrzenną poziomu ubóstwa badano za pomocą wskaźnika lokalizacji oraz lokalnej statystyki Morana (LISA). Wyniki badań pozwoliły wskazać wyraźny wzorzec przestrzenny manifestujący się w postaci podwyższonego poziomu ubóstwa w centrum Łodzi. Wyróżniono także szereg klastrów, tj. skorelowanych przestrzennie kwartałów o wysokim udziale zasiłkobiorców oraz towarzyszące im obszary wysokich kontrastów analizowanego zjawiska.

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.

Objectives Methamphetamine (MA) is a widely used illicit drug and a nationwide public health concern. Although dental complications are consistently reported among MA users, yet limited nationally representative studies on the associations between MA use and oral health currently exist. Methods Using the National Health and Nutrition Examination Survey 2009-2014, we analyzed 8,762 respondents aged 30-64 years who had completed a periodontal examination. MA use was self-reported; periodontitis, untreated caries, and missing teeth were assessed by calibrated dentists. Descriptive statistics as well as multivariable regression analyses were performed. Data were weighted to yield representative estimates of the US adult population. Results Overall 7.8 percent of US adults aged ≥30 years had ever used MA. Ever-use prevalence was higher among males, whites, and individuals below the federal poverty level. Established MA users had a higher prevalence of untreated dental caries (36.6 percent), any periodontitis (54.8 percent), and severe periodontitis (12.2 percent) than those who had never used MA. The prevalence of any periodontitis was higher among current MA users (PR: 1.31; 95% CI: 1.05-1.62) than those who never used MA. Prevalence of untreated dental caries was higher among current MA users (PR: 1.53; 95% CI: 1.10-2.13) and established users (PR: 1.21; 95% CI: 1.02-1.48) than never users. Taking MA orally and/or through injection was associated with higher odds of severe periodontitis than orally only (AOR: 3.72; CI: 1.79-7.75). Conclusions MA users had a higher prevalence of periodontitis and dental caries. Continued research assessing the relationship between MA use and oral health can inform clinical interventions and management of dental diseases in MA users.

Objective To examine whether low-income children's use of preventive dental services is linked to variation in state Medicaid policies that affect parents' access to dental care in Medicaid. Data sources Medical Expenditure Panel Survey (2011-2016), Area Health Resources File, and Medicaid adult dental coverage policies. Study design We conducted a quasi-experimental analysis using linked parent-child dyads in low-income families (≤125 percent of the Federal Poverty Level). We assessed whether expansions of Medicaid to low-income adults under the Affordable Care Act were associated with increases in the use of preventive dental services among low-income children when state Medicaid programs did vs did not cover these services for adults. Principal findings Over the study period, 37.8 percent of low-income children received at least one annual preventive dental visit. We found no change in children's receipt of preventive dental care associated with Medicaid expansions in states that covered (1.26 percentage points; 95% CI: -3.74 to 6.27) vs did not cover preventive dental services for adults (3.03 percentage points; 95% CI: -2.76 to 8.81). (differential change: -1.76 percentage points; 95% CI: -8.09, 4.56). However, our estimates are imprecise, with wide confidential intervals that are unable to rule out sizable effects in either direction. Conclusion We did not find an association between Medicaid expansions with concurrent coverage of preventive dental services for adults and children's use of these services. Factors other than parental access to dental benefits through Medicaid may be more salient determinants of preventive dental care use among low-income children.

Background: Several studies have reported differential vaccine uptake outcomes that are associated with sociodemographic and socioeconomic characteristics, as well as provider type. However, none has examined a trend over a multiple-year span. In this study, we utilize a longitudinal data-based approach to examine state-level human papillomavirus (HPV) vaccine trends and their influences over time. Methods: We analyzed National Immunization Survey – Teen data (2008–2016) to estimate HPV vaccine initiation rate in young female adolescent ages 13–17 years old among U.S. States. We identified growth patterns using the latent class growth method and explored state-level characteristics, including socioeconomic and sociodemographic attributes, and health legislation and policy-related programs among patterns. Results: We identified three growth patterns, which showed gradually increasing vaccination trends but different baseline HPV uptake rates (high, moderate, low). States within Pattern 1 (highest HPV vaccination rates) included the lowest percentage of families with incomes below federal poverty level, the highest percentage of bachelor's degree or higher, and the lowest number of uninsured, while states within Pattern 3 (lowest HPV vaccination rates) included families with socioeconomic attributes along the opposite end of the spectrum. Conclusions: Latent class growth models are an effective tool to be able to capture health disparities in heterogeneity among states in relation to HPV vaccine uptake trajectories. Impact: These findings might lead to designing and implementing effective interventions and changes in policies and health care coverage to promote HPV vaccination uptake for states represented under the lowest trajectory pattern.

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]).

This paper describes sociodemographic, sexual risk behavior, and clinical care factors associated with sustained viral suppression (SVS) among heterosexual Black men with diagnosed HIV in the US. Sample was 968 men, 2015-2017 cycles of Medical Monitoring Project. We used prevalence ratios and a multivariable logistic regression model to identify independent predictors of SVS. About 9% of sexually active men had sex that carries a risk of HIV transmission. Nearly 2/3 lived at or below the poverty level, 13% were under or uninsured, 1/4 experienced food insecurity and 15% reported recent homelessness. About 26% were not engaged in HIV care, 8% not currently taking antiretroviral therapy (ART) and 59% had SVS. Among men taking ART, care engagement and adherence were the only significant independent predictors of SVS. Efforts to increase VS should focus on increasing ART use, care engagement, and ART adherence, and include strategies that address the social and structural factors that influence them.

Poverty is a persistent problem in Indonesia, especially in rural areas. The poor population in rural areas by their livelihood as farmers, and 75% of the poor farmers are food crop farmers, especially rice farmers. The purpose of this study is to analyze the income and feasibility of farming and the poverty level of rice farmer household. This research was conducted in an area where most of the population is rice farmers. This study uses a qualitative descriptive method by analyzing quantitative data through income analysis and farm feasibility and poverty rates of farm household according to Sayogyo. Research shows that rice farming produces 1,845 kg with an income of IDR. 16,605,000 based on local rice prices, IDR. 9,000/kg. While the total costs incurred by farmers are IDR. 3,596,000 so that the household income of rice farmers is IDR. 13,009,000/year with an R/C value of 1.3. Based on the value of the household income of rice farmers with an average number of family dependents of 5 people, it can be determined the poverty level criteria that are equivalent to the level of rice consumption that is equal to 289.1 kg/person/year. Thus, rice farming households according to Sayogyo are in the criteria between "Very Poor" and "Poor" household with household income equivalent to 240-320 kg of rice/person/year. Because it has a feasibility value of more than 1, the rice farming has a comparative advantage, but the feasibility value has not been able to alleviate the rice farmer household of poverty.

Poverty is a level of life that below the minimum standard of living needs. The dominant factors that influence the emergence of poverty include education, income, location, limited access to health, finance and public services. Poverty is also one of the crucial issues in West Bandung Regency, where West Bandung Regency has the highest poverty rate compared to surrounding areas such as Bandung City, Bandung Regency, and Cimahi City. The purposes of this study are to analyze the pattern of spatial poverty distribution in general (Moran Index) and in each village (2) Analyze the factors that influence poverty in West Bandung Regency, which are carried out in 165 villages. The results of this study state that there was a positive spatial autocorrelation of 0,464173 which indicated the existence of a link between the poor population in each village and the pattern of poverty that clustered. The LISA test showed the poverty level of the population was clustered into four poverty clusters, namely 17 villages that were in the high-high criteria, 31 villages in the low-low criteria, 5 villages in the low-high criteria and 1 village in the high-low criteria . The factors that influenced poverty in West Bandung Regency were population, education level, village fund allocation, number of groceries, and village funds, while the village index builds, the distance of villages to the capital and the number of people using National electrical corporate (PLN) were not significant to reduce poverty.

Objective:To examine trends from 2015 to 2017 in dietary behaviours and diet quality among low-income mothers, teenagers and children.Design:Cross-sectional telephone surveys using a validated 24 h dietary assessment.Setting:Randomly sampled households with incomes ≤185 % of the US federal poverty level across California.Participants:Survey participants were 13 247 mothers (≥18 years), 3293 teenagers (12–17 years) and 6043 children (5–11 years). Respondents were mostly Latino.Results:Over the 3-year study period, consumption of fruits and vegetables with and without 100 % fruit juice increased (P ≤ 0·05) by at least 0·3 cups/d for mothers, teenagers and children. Intake of water also increased (P ≤ 0·001) by more than 1 cup/d for mothers and children and 2 cups/d for teenagers. Sugar-sweetened beverage (SSB) consumption was unchanged over the 3 years. Overall diet quality, as assessed by the Healthy Eating Index-2015, improved (P ≤ 0·01) for mothers, teenagers and children. Covariates for the fifteen regression models (three age groups by five outcome variables) included race/ethnicity, age, education for mothers, and gender for teenagers and children.Conclusions:The observed increases in fruit and vegetable intake and improvements in overall diet quality during the 3-year period suggest that low-income Californians may have lowered their risk of preventable diseases. However, more intense or strategic SSB-reduction interventions are required. Regional- or state-level, population-based surveillance of dietary behaviours is useful for public health nutrition policy and programme decision making, and can be used to assess potential trends in future negative health outcomes and related costs associated with poor dietary behaviours within at-risk populations.

People living with HIV (PLWH) who experience homelessness have poorer clinical outcomes than people with HIV who are not homeless; however, there is limited information on PLWH who experience other forms of housing instability. We used interviews and medical record abstraction data from the Medical Monitoring Project, collected 2018-2019 (N = 4,050), to describe sociodemographic characteristics and clinical outcomes of adults with HIV by whether people experienced unstable housing in the past 12 months. Overall, 21% were unstably housed, of which 55.2% were unstably housed but not homeless. People who were unstably housed were more likely to be younger, have lower educational attainment, be previously incarcerated, live at or below the poverty level, and have poorer mental health and clinical outcomes, independent of homelessness. Interventions to address housing instability, integrated with clinical care, could benefit not just PLWH who are homeless but also those who are unstably housed.

Importance In the US, safety concern has been identified as a primary barrier to initiating the human papillomavirus (HPV) vaccine. It is unclear if the public's sentiment concerning HPV vaccine safety aligns with postmarketing vaccine safety surveillance data. Objective To perform a parallel assessment of trends in HPV vaccine safety concerns and HPV vaccine adverse event (AE) reporting. Design, Setting, and Participants This study was a cross-sectional analysis of the National Immunization Survey (NIS) and Vaccine Adverse Event Reporting System (VAERS). Participants in the NIS were adolescents aged 13 to 17 years. AEs were reported to VAERS by patients, health care clinicians, or other sources. Statistical analysis was performed from October 2020 to May 2021. Main Outcomes and Measures Secular trends in HPV vaccine safety concerns and spontaneous AE reporting for HPV vaccination from 2015 to 2018. Results Caregivers of 39 364 unvaccinated adolescents with a mean (SD) age of 15.57 (0.08) years (26 996 White adolescents [62.9%], 22 707 male adolescents [56.1%], 11 392 privately insured [62.6%], and 32 674 above the poverty level [79.3%]) reported their reasons for not initiating the HPV vaccine series in the 2015-2018 NIS. Citing safety concerns as the primary reason for not initiating the HPV vaccine series increased from 13.0% (95% CI, 12.1%-14.0%) in 2015 to 23.4% (95% CI, 21.8%-25.0%) in 2018 (P for trend

Background: The 2006 Surgeon General’s Report recommended the elimination of smoking in homes as an effective protective measure against the harmful effects of secondhand tobacco smoke exposure. This study aims to examine trends in the prevalence and levels of the adoption of home tobacco use policies specifically for cigarettes, e-cigarettes, smokeless tobacco, and the relationships between home tobacco use policies and self-reported exposure to secondhand tobacco smoke. Methods: This study utilizes data from Wave 1 (2013–2014) through Wave 4 (2016–2018) of the Population Assessment of Tobacco and Health (PATH) Study, a large prospective cohort study of youths and adults in the United States which collected information about both smoke-free and tobacco-free home policies. We present the weighted, population-based, self-reported prevalence of home tobacco use policies overall and by product, and the average number of self-reported hours of secondhand smoke (SHS) exposure by levels of home tobacco policy and by survey wave. In addition, we examine the characteristics of those who adopted (by yes or no) a home tobacco use ban between survey waves. Results: We found a high prevalence of completely tobacco-free home policies (69.5%). However, 10.6% of adults allow the use of any type of tobacco product inside their homes, and 19.8% have a policy allowing the use of some types of tobacco products and banning the use of others. Adults with a complete tobacco use ban inside their homes were more likely to be nonusers of tobacco (79.9%), living with children in the home (71.8%), at or above the poverty level (70.8%), non-white (76.0%), Hispanic (82.7%), and aged 45 or older (71.9%). The adoption of 100% tobacco-free home policies is associated with a 64% decrease in secondhand smoke exposure among youths and a 69% decrease in exposure among adults. Conclusions: Most US adults have implemented tobacco-free home policies, however, there is still exposure to SHS in the home, for both adults and children, particularly in the homes of tobacco users. Additional research should investigate tobacco-free home policies for different types of products and what effect they have on future tobacco use behaviors.

BackgroundThe sociodemographic predictors of either out-of-pocket expenditure (OOP) or underinsurance among skin cancer survivors is not well reported in the literature. In this study we estimated all-cause healthcare related OOP expenditure and probability of underinsurance among insured skin cancer survivors and identified the sociodemographic predictors of these measures.Data and MethodWe pooled Medical Expenditure Panel Survey (MEPS) data from 2011 to 2015 and identified skin cancer using Clinical Classifications Software (CCS) code. Only adult (≥18 years) skin cancer survivors with full year insurance coverage were included in our study (n = 1825). We used a generalized linear model (GLM) with log link and gamma distribution to estimate OOP and a logit model to estimate the probability of underinsurance. We estimated the Average Marginal Effect (AME) to quantify the variations and their statistical significance between reference level and other levels of each predictor. Our analyses accounted for the complex survey design of MEPS.ResultsThe average all-cause OOP was $1766 per person per year for a skin cancer survivor. Among all skin cancer survivors, females, those aged 60-64 years, with some college education or a degree, with income ≥400% of federal poverty level (FPL) and with non-managed-care private insurance incurred significantly higher OOP expenditure compared to their respective counterparts. In terms of underinsurance, females and those aged 60-64 years had higher probability, whereas, survivors with non-white race/ethnicity and income 200% of FPL or higher had lower probability of being underinsured compared to their respective counterparts.ConclusionOur study demonstrates that OOP expenditure and underinsurance varies significantly by sociodemographic factors among skin cancer survivors.

The objective of this research is to compare the Day 1 and Day 2 dietary intakes of adults in What We Eat in America, National Health and Nutrition Examination Survey (WWEIA, NHANES) 2013–2016. Dietary recalls of males (n = 2599) and females (n = 2624) 20+ years who had both a Day 1 and Day 2 recall and reported their intake as usual on both days in WWEIA, NHANES 2013–2016 were examined. Mean (±SE) energy intake for males was 2425 ± 26 kcal for Day 1 and 2334 ± 32 kcal for Day 2 (p = 0.004). For females, 1832 ± 18 kcal and 1775 ± 26 kcal were reported for Day 1 and 2, respectively (p = 0.020). There were no significant differences between energy intake on Day 1 and Day 2 within males and females by ten-year age groups. Comparing 20 year age groups for males and females by race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic) and income (&lt, 131%, 131–350%, and &gt, 350% of poverty level) also showed no significant differences in energy intake between Day 1 and Day 2. Mean energy intake of adults was not statistically different between the two days of recall by sex, race/ethnicity or income within selected age groups. Overall, the difference in energy intake was less than 4% for both males and females.

Despite implementation of the Affordable Care Act (ACA), many Americans remain uninsured and receive care in free clinics. It is unknown what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. The objective of this study was to assess the perceptions and experiences of free clinic patients from southwestern Pennsylvania when applying for health insurance after implementation of the ACA. We designed and implemented a survey of patients at three free clinics within Allegheny County, Pennsylvania from September 2016 to February 2017. Our survey included 22-items, 7 sociodemographic questions and 15 questions regarding the patient's health status and their perspectives related to obtaining health insurance. Data was obtained from 203 patient surveys; 110 (55.3%) of the respondents were men and 99 (48.8%) were African American. There were 48 respondents (24.1%) who did not report any income at the time of the study, and of those that did report an income, 92 (46.2%) respondents reported an income below 133% of the federal poverty level. The main barriers patients faced when applying for health insurance were: (1) lack of knowledge about health insurance (n = 127, 58.1%), (2) cost of health coverage (n = 85, 41.9%), (3) lack of resources (n = 83, 40.4%), and (4) lack of enrollment documentation (n = 43, 23.8%). Significant work is needed to better educate patients about their eligibility and options for health insurance. Free clinics can play a key role in eliminating barriers to health insurance enrollment.

Background: Little is known about variation in meeting the 24-Hour Movement Guidelines (including physical activity [PA], sleep, and screen time [ST]) in early childhood. The aim was to evaluate sociodemographic differences in meeting the 24-Hour Movement Guidelines. Methods: Parents of 3–4 year old children reported sociodemographic information and ST. Sleep and PA were measured using accelerometry, and height and weight were objectively measured. The 24-Hour Movement Guidelines include daily PA (total PA: ≥3 h; including ≥1 h of moderate to vigorous), sleep (10–13 h), and ST (≤1 h). Meeting guidelines by age, sex, race, poverty level, and weight status were assessed using chi-square and linear regression models. Results: Of 107 children, 57% were white and 26% lived in households at or below the poverty level. Most children met the PA (91.5%) and sleep (86.9%) guidelines, but few met ST (14.0%) or all 3 (11.3%) guidelines. African American children and children who lived at or below the poverty level were less likely to meet the sleep, ST, and all 3 guidelines compared with others (P Conclusion: These results suggest future interventions should focus on reducing differences in movement, namely in sleep and ST.

This study examined the association between place of service and adherence to select diabetes screening measures in a homeless population. At a Midwestern metropolitan federally qualified health center (FQHC), 508 participants with diabetes and also experiencing homelessness were studied throughout calendar year 2018. Diabetes measures included controlled blood pressure, diabetic foot exam and hemoglobin A1C screening. Patients were seen at one of three locations: FQHC only, shelter only and both shelter and FQHC. After controlling for primary insurance, insurance status, homeless status, age group, ethnicity, primary language, race, sex and poverty level, a stepwise binary logistic regression demonstrated significant model improvement in A1c screening (p ≤ 0.001) and controlled blood pressure (p = 0.009) when place of service was added as a predictor. Specifically, results showed significant negative associations in screening adherence for shelter as compared to FQHC for both controlled blood pressure (OR = 0.40; 95% CI = 0.20-0.79; p = 0.009) and A1c screening (OR = 0.06; 95% CI = 0.03-0.16; p ≤ 0.001). Our results support the hypothesis that FQHC care results in higher rates of adherence than shelter only or FQHC and shelter combined care. The study addresses the gap in literature surrounding place of service and patient adherence. Recommendations for future research are included.

This research was conducted in the Southwest Sumba regency, East Nusa Tenggara Province. This regency has a great potency of natural resources but with higher poverty level due to the low human resources, limited investments and available technology. The poverty can be solved through the development of sustainable horticulture agribusinesses. The multi-dimensional scaling (MDS) analysis, as a modification of the rapid appraisal of the Status of Farming (RAP-farm) method, was used in this study. The results of the analysis showed that sustainability status of the development of horticulture agribusiness in the Southwest Sumba regency was less sustainable, valued 43.72. This value was obtained according to the assessment of 37 parameters from five dimensions with different sustainability statuses, of which only ecology was quite sustainable (52.12), whereas economy (49.01), social (46.76), technology (43.8), and institutions (48.91) were less sustainable. The sensitive parameters toward the development of sustainable horticulture agribusinesses were (1) land slope and erosion frequency, (2) horticulture products prices and cultivated lands sizes, (3) government service existences and the assistance and extension intensity, (4) soil preparation techniques and compost making, and (5) the existence and conflicts among the farmer groups. Keywords: poverty, horticulture, agribusiness, sustainability, Southwest Sumba.

This survey investigation assessed an economically challenged and largely minority population regarding concerns, evacuation status, medical needs and access to care during, and after, Hurricane Sandy by ethnicity status for patients using New Jersey’s Federally Qualified Health Centers (FQHC). Data obtained contribute to understanding risk from disasters, and improving environmental justice for vulnerable populations following disasters. FQHCs provide medical and dental services for 5% of New Jersey ‘s population; 95% of those served are uninsured, underinsured, or live below the poverty level. Economically vulnerable individuals are more at risk and were disproportionately harmed by Sandy. There were ethnic differences in days evacuated, days without power and heat, self-rating of personal/family impact, center use, need and access, and interruptions of care and medications. Hispanics and Blacks reported needing centers significantly more than White population. Primary medical conditions were diabetes, asthma, hypertension, and arrhythmia and heart disease, which did not vary ethnically. Understanding medical needs and concerns of vulnerable populations may help policy makers and practitioners prepare and respond promptly to disasters, reducing risk, and building resiliency for the medical care system.

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.

BackgroundSocioeconomic factors may impact the efficiency of COVID vaccine rollout; however, there are limited studies that examine how state socioeconomic status influences the speed of vaccine distribution. This study aimed to demonstrate how employment rates as one of the main socioeconomic factors affect vaccine coverage in 50 states of the United States.MethodsThis study has obtained vaccine data for the 50 states in the United States, available in the electronic online database ourworldindata.org. In addition to employment rates, other socioeconomic determinants including poverty level, uninsured rates, population density, homeownership, educational level, the percentage of the elderly population, and educational level were obtained from ourworldindata.org data platform. Data from these 50 states were used for regression analyses to examine the relationship between socioeconomic and vaccination rates.ResultsOur study revealed a positive linear association between unemployment and vaccine rates, and states with higher unemployment rates were more likely to have higher vaccination rates. However, other socioeconomic measures do not significantly associate with vaccine coverage.ConclusionDespite other studies showing that vulnerable populations had lower vaccine rates, this study shows that states with higher unemployment rates are more likely to be vaccinated. However, the finding suggests a need for more research for the states with higher than 5% unemployment rates, as they had a lower vaccine coverage than states with a range of 4% to 5% unemployment rates.

Poverty is a problem of economic development which is always an interesting discussion. Poverty has an impact on socio-economic burdens, increases in crime, decreases the quality of life, and hinders the creation of superior human resources. The objectives of this study were to 1) analyze the concept and development of poverty in West Sumatra Province; and 2) to analyze the effect of macroeconomic indicators on poverty in West Sumatra Province. The macroeconomic indicators used are Economic Growth Rate based on Gross Regional Domestic Product (GRDP) and Human Development Index (HDI). The analytical tool used is multiple linear regression which includes data from 19 districts and cities in West Sumatra Province during the period 2015-2019. From the results of this study, it was found that in general the poverty rate in West Sumatra Province from 2015-2019 continued to decline. The variable rate of economic growth has a positive relationship with the level of poverty in West Sumatra Province. Meanwhile, the HDI variable has a significant effect on the poverty level and has a negative relationship.

Background Dermatology practice has recently seen multiple changes. A better understanding of trends pertaining to dermatology practice setups is necessary. Objective To analyze the recent changes in dermatology practice in terms of geography, practice size, and gender distribution as well as to analyze the availability of dermatologists based on zip codes' income levels. Methods This was a cross-sectional study. We extracted data on the sex and billing addresses of dermatologists from Medicare provider utilization and payment data for 2012 and 2017. We used 2017 tax returns data to calculate the poverty level for each zip code. Results Between 2012 and 2017, the number of solo practitioners decreased, while that of dermatologists working in large groups increased. The southern region experienced the largest changes. The male-to-female ratio decreased. Dermatology practices mainly comprised mixed genders, with a higher proportion of all-male groups versus that of all-female groups, but this difference decreased over time. In the northeastern and western regions, more than one third of dermatologists were located in the wealthiest zip codes. Limitations The Medicare data may not be exhaustively representative of the dermatology workforce, and the zip codes of 489 dermatologists' billing addresses were missing in the tax return dataset. Conclusions These findings provide an understanding of the recent changes pertaining to dermatology practice setups and of the substantial health care disparities based on geographic distribution.

We characterize social welfare and health care needs of women who inject drugs in a community-based survey in San Francisco. A total of 139 women were enrolled; 74.8% were homeless, and 67.6% earned below poverty level. Indicators of health care and prevention program access included: 95.7% with health insurance, 90.6% used a needle exchange program, and 58.2% tested for HIV two or more times. However, only 8.6% received HPV vaccination and there was unmet contraception need for 79.0% of women. Only 28.7% of those testing positive for HCV infection had received treatment. Physical and sexual violence in the last year were common (41.0% and 18.0%, respectively). Women who inject drugs would benefit from integrated health and social services including addressing interpersonal violence, sexual and reproductive health, and HIV and HCV prevention needs. Women-only needle exchange programs and safe injection sites may be effective delivery points for these services.

Purpose: Poverty is a risk factor for poor child health outcomes, and these risks may be more pronounced in high risk populations, including those in the child welfare system. The objective of our study was to analyze the association between family poverty level and child health outcomes in school-aged children referred to protective services for abuse or neglect. Methods: We conducted a secondary analysis using longitudinal cohort data of school-age children 5-9 years old from the Second National Survey of Child and Adolescent …

Introduction Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS). Methods We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state. Results Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries. Conclusion We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.

Background The dual burden of poor diet quality and food insecurity makes free food—food acquired at no cost—a very important part of the nutrition safety net for low-income families. The goal of this study was to determine the national prevalence and nutritional quality of free food acquired separately in two settings: 1) by children at school; and 2) by employees at work; both stratified by participation in the Supplemental Nutrition Assistance Program (SNAP). Methods Using National Household Food Acquisition and Purchase Survey data (2012; n = 4,826 U.S. households containing 5,382 employed adults and 3,338 school-aged children), we used survey-weighted proportions to describe free food acquisition and linear regression to compare the 2010 Healthy Eating Index (HEI-2010) for free/non-free food acquisition events (i.e., meals) by SNAP status. Analyses were conducted in 2019–2020. Results SNAP households had more free acquisition events (29.6%) compared to non-SNAP households ( Conclusions Over one fifth of all food acquisition events were free, but free food acquisitions at school and work were relatively unhealthy. For children participating in SNAP, free food acquired at school had higher nutritional quality. Improving the dietary quality of free foods could improve the health of families, especially those participating in SNAP.

In the United States, one in four adults is living with a disability. Age-related changes, disease-related pathology and treatments can place a person with HIV at risk for a disability. We analyzed nationally representative data to describe disability status among adults ≥18 years with diagnosed HIV in the United States and Puerto Rico by demographic characteristics, health behaviors, quality of care, clinical outcomes and mental health status. We reported weighted percentages and prevalence ratios with predicted marginal means to evaluate significant differences between groups (P < .05). Overall, 44.5% reported any disability; the most frequently reported disabilities were related to mobility (24.8%) and cognition (23.9%). Persons who lived in households at or below the poverty level or who experienced homelessness in the last 12 months reported a higher prevalence of any disability than persons who were not poor or not homeless (60.2% vs. 33.4% and 61.8% vs. 42.8%, respectively). Prevalence of depression and anxiety was higher among persons with any disability compared with those with no disability (32.8% and 26.6% versus 10.1% and 7.0%, respectively). Enhancing support from clinicians and ancillary providers may help optimize long-term health outcomes among HIV-positive persons with disabilities.

* Abbreviations: ACA — : Affordable Care Act COVID-19 — : coronavirus disease ESI — : employer-sponsored insurance FPL — : federal poverty level In addition to the devastating health effects of the coronavirus disease (COVID-19) pandemic, the United States is experiencing the highest rates of unemployment since the Great Depression.1 One important and overlooked consequence of unemployment is the loss of employer-sponsored insurance (ESI) coverage for children whose parents lose their jobs. It is estimated 27 million US adults will become uninsured because of unemployment and lose ESI during the pandemic.2 During the pandemic, >4 out of 10 parents with children

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.

Objectives/hypothesisDuring the current COVID-19 pandemic, the demand for direct-to-home telemedicine services has risen to an unprecedented level. Equal access to specialty care was assessed to identify potential barriers that may negatively impact telemedicine utilization.Study designRetrospective case series.MethodsWe examined the 6-week period between March and May 2020 when the only access to nonurgent pediatric otolaryngology service was through telemedicine and compared it to in-person visits during the same period in 2019. We compared patient demographics, including age, gender, preferred language, zip code of residence, and primary insurance plan.ResultsA total of 1,495 visits were conducted through telemedicine from March 23, 2020 to May 1, 2020, and 1983 in-person visits were completed in 2019. There was no difference in patient age and gender. The proportions of Spanish-speaking families were similar (15.8% in 2019 vs. 14.4% in 2020, P = .96). The percentage of Medi-Cal-insured patients (51.4% in 2019 vs. 49.8% in 2020, P = .73) and the mean poverty level (12.6% in 2019 vs. 12.2% in 2020, P = .38) also remained the same. Spanish-speaking families were statistically more likely to require rescheduling of their telemedicine visits (17.2%) when compared to the overall rescheduling rate of 11.9% (P = .0083).ConclusionsWe were able to successfully provide access to telemedicine services to our vulnerable populations during the current COVID-19 pandemic. Telemedicine is likely to remain an essential mode of delivering patient care going forward. It is important to evaluate and identify potential disparities to telemedicine access and proactively implement changes to address these barriers.Level of evidence4. Laryngoscope, 131:1175-1179, 2021.

Background Unsafe disposal of children’s stool makes children susceptible to fecal-oral diseases and children remain vulnerable till the stools of all children are disposed of safely. There is a paucity of data on spatial distribution and factors associated with unsafe child stool disposal in Ethiopia. Previous estimates, however, do not include information regarding individual and community-level factors associated with unsafe child stool disposal. Hence, the current study aimed (i) to explore the spatial distribution and (ii) to identify factors associated with unsafe child stool disposal in Ethiopia. Methods A secondary data analysis was conducted using the recent 2016 Ethiopian demographic and health survey data. A total of 4145 children aged 0–23 months with their mother were included in this analysis. The Getis-Ord spatial statistical tool was used to identify high and low hotspots areas of unsafe child stool disposal. The Bernoulli model was applied using Kilduff SaTScan version 9.6 software to identify significant spatial clusters. A multilevel multivariable logistic regression model was fitted to identify factors associated with unsafe child stool disposal. Results Unsafe child stool disposal was spatially clustered in Ethiopia (Moran’s Index = 0.211, p-value< 0.0001), and significant spatial SaTScan clusters of areas with a high rate of unsafe child stool disposal were detected. The most likely primary SaTScan cluster was detected in Tigray, Amhara, Afar (north), and Benishangul-Gumuz (north) regions (LLR: 41.62, p Conclusions Unsafe child stool disposal was spatially clustered. Higher odds of unsafe child stool disposal were found in households with high community poverty level, poor, unimproved toilet facility, and with the youngest children. Hence, the health authorities could tailor effective child stool management programs to mitigate the inequalities identified in this study. It is also better to consider child stool management intervention in existing sanitation activities considering the identified factors.