Title: Social networks and social support among older adults in rural South Africa: Findings from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH community in South Africa
Working paper #: Volume 17, No. 1
Author(s): Guy Harling, Katherine Ann Morris, Lenore Manderson, Jessica M. Perkins, and Lisa F. Berkman
Objectives: We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH community in South Africa (HAALSI) study in rural South Africa to examine how age and gender interact to predict older adults’ social networks and receipt of social support in rural South Africa.
Method: We used regression analysis on data for 5059 adults aged over 40. We examined how network size, density, and communication and social support receipt were associated with gender and age, as well as with kin, gender and geographic composition.
Results: Older respondents reported fewer important social network ties, greater network density and less frequent communication than their middle-aged peers, largely due to fewer non-kin connections. Women had smaller networks, and difference in networks size was greater between older and younger women than among men. Older women had fewer non-kin ties living in the same village than younger women; older men’s lower levels of contact relative to middle-aged men in some spheres were offset by more female and co-resident ties.
Discussion: In contrast to the extant literature, older women in this study area had more limited social network and support than their male peers, and may thus benefit from targeted interventions.
Title: Who benefits from social investment? The gendered effects of childcare, employment, and family policies on cardiovascular disease in Europe
Working paper #: Volume 17, No. 2
Author(s): Katherine Ann Morris, Clare Bambra, and Jason Beckfield
In the context of fiscal austerity in many European welfare states, policy innovation often takes the form of “social investment,” a contested set of policies aimed at strengthening labor markets and fostering gender equity. Social investment policies include employment subsidies, skills training, job-finding services, early childhood education and childcare, and public support for parental leave. Given that such policies can enhance gender equity in the labor market, we analyzed the possible effects of such policies on gender health equity. Using age- and sex-stratified data from the Global Burden of Disease Study on cardiovascular disease morbidity and mortality, and policy indicators on employment supports, childcare, and parental leave from multiple sources, we find mixed effects of social investment for men versus women. Government spending on public employment services and the percent of children in early childhood education or care are associated with lower mortality rates for men, but the associations are not significant for women. Government spending on employment training and the number of eligible weeks of paid parental leave are associated with lower mortality rates for women, but the associations are not significant for men. Government spending on paid parental leave is associated with lower mortality rates for both men and women, although with a stronger association for women. Finally, government spending on early childhood education and care is associated with lower mortality rates for both men and women equally. We discuss the implications of these effects for gender equity, and of these findings for the social investment policy turn and future research on gender health equity.
Working paper #: Volume 17, No. 3
Author(s): Onur Altındag, Ozan Bakis, and Sandra Rozo
We study the impact of more than 3 million Syrian refugees on Turkish businesses operating in an economy with a large informal sector. We use an instrumental variable design that relies on exogenous variations in refugee outflows from Syria and the geographic location of Arabic-speaking communities in Turkey before the conflict began. Using yearly censuses of firms, we find that refugee inflows had a positive impact on the intensive and extensive margins of production, which are highly concentrated in the informal economy. The effects are stronger for smaller firms and those that operate in the construction and hospitality industries.
Working paper #: Volume 17, No. 4
Author(s): Ludovico Carrino, Karen Glaser, and Mauricio Avendano
This paper examines the health impact of UK pension reforms that increased women’s State Pension age for up to six years since 2010. Exploiting an 11% increase in employment caused by the reforms, we show that rising the State Pension age reduces physical and mental health among women from routine-manual occupations. We show robust evidence that a larger increase in the State Pension age leads to larger negative health effects, resulting in a widening gap in health between women from different occupations. Our results are consistent with a 27% fall in individual incomes for women in routine-manual occupations.
Title: Socioeconomic and gender inequalities in neonatal, postneonatal, and child mortality in India: A repeated cross-sectional study, 2005-2016
Working paper #: Volume 18, No. 1
Author(s): Omar Karlsson, Rockli Kim, William Joe, and SV Subramanian
In India, excess female mortality, primarily concentrated in the postneonatal period, is well documented. Deaths in early childhood are also known to be patterned by socioeconomic factors. This study examines sex differentials and sex-specific wealth gradients in neonatal, postneonatal, and child mortality in India using repeated cross-sectional data from the Indian National Family Health Surveys conducted in 2005-06 and 2015-16. Overall, boys had greater neonatal mortality and the difference increased over time. Girls had greater postneonatal and child mortality, overall, but the difference decreased over time. A negative wealth gradient was found for all mortality outcomes for both boys and girls. Neonatal mortality was persistently greater for boys than girls over most of the household wealth distribution. Girls had greater child mortality at low levels of wealth and greater postneonatal mortality over much of the wealth distribution. The wealth gradient in neonatal mortality decreased for girls and increased for boys. Female child mortality had a substantially stronger wealth gradient but the difference decreased over the period. Not distinguishing between neonatal, postneonatal and child mortality masks important sex and socioeconomic disparities in under-5 mortality in India.
Now Published in Journal...
Journal of Epidemiology & Community Health: Socioeconomic and gender inequalities in neonatal, postneonatal and child mortality in India: a repeated cross-sectional study, 2005–2016
Title: Estimates of child malnutrition indicators for 543 parliamentary constituencies in India, 2016: A visual and tabular representation
Working paper #: Volume 18, No. 2
Author(s): Rockli Kim, Yun Xu, William Joe, and SV Subramanian
In this brief report, and building on a previous study (6), for the first time, we present robust estimates on five indicators of child malnutrition (i.e., stunting, underweight, wasting, low birth weight, anaemia) for each PC in India. We provide ranking of the PCs both on the (i) average prevalence of the five indicators; and (ii) the degree of “Between-Village” inequality in the prevalence estimate on the five indicators. Thus, even if a PC is doing well on average, large inequalities within a PC (between its villages) suggests the need for further precision geo-targeting.
Title: FAQs on Child Anthropometric Failures in India: Insights from the National Family Health Survey 2015-16
Working paper #: Volume 18, No. 3
Author(s): Sunil Rajpal, Rockli Kim, Rajan Sankar, Alok Kumar, William Joe and SV Subramanian
Nutritional well-being is central for achievement of several prominent national and international development goals. Despite considerable efforts and increasing policy commitments, India is yet to witness meaningful reductions in the burden of child undernutrition. We analyse the latest National Family Health Survey to develop critical policy insights to catalyse the reductions in child anthropometric failures in India. We describe that the POSHAN targets are far from modest and will require greater contribution from poor-performing states. The two fundamental concerns as reflected by this analysis are non-response of economic growth on nutritional well-being and greater burden among the poor. This calls for strengthening developmental finance for socioeconomic upliftment as well as enhanced programmatic support for nutritional interventions. The gaps in analytical inputs for programmatic purposes also deserves attention to unravel intricacies that otherwise remain obscured through customary enquiries. On one hand, this may serve well to improve policy targeting and on the other can help comprehend the nature and reasons of heterogeneities and inequities in nutritional outcomes across groups and geographies. In conclusion, we recommend strengthening analytical capacities of programme managers and health functionaries.
Title: Parliamentary Constituency Factsheet for Indicators of Nutrition, Health and Development in India
Working paper #: Volume 18, No. 4
Author(s): Rockli Kim, Akshay Swaminathan, Goutham Swaminathan, Rakesh Kumar, Sunil Rajpal, Jeffrey C. Blossom, William Joe, and SV Subramanian
In India, data on key developmental indicators that formulate policies and interventions are routinely available for the administrative units of districts but not for the political units of Parliamentary Constituencies (PC). Members of Parliament (MPs) in the Lok Sabha, each representing 543 PCs as per the 2014 India map, are the representatives with the most direct interaction with their constituents. The MPs are responsible for articulating the vision and the implementation of public policies at the national level and for their respective constituencies. In order for MPs to efficiently and effectively serve their people, and also for the constituents to understand the performance of their MPs, it is critical to produce the most accurate and up-to-date evidence on the state of health and well-being at the PC-level. However, absence of PC identifiers in nationally representative surveys or the Census has eluded an assessment of how a PC is doing with regards to key indicators of nutrition, health and development.
In this report, we present PC estimates for 100+ indicators of nutrition, health and development derived from two data sources.
Title: Revealing the unequal burden of COVID-19 by income, race/ethnicity, and household crowding: US county vs. ZIP code analyses
Working paper #: Volume 19, No. 1
Author(s): Jarvis Chen and Nancy Krieger
No national, state, or local public health monitoring data in the US currently exist regarding the unequal economic and social burden of COVID-19. To address this gap, we draw on methods of the Public Health Disparities Geocoding Project, whereby we merge county-level cumulative death counts with population counts and area-based socioeconomic measures (ABSMs: % below poverty, % crowding, and % population of color, and the Index of Concentration at the Extremes) and compute rates, rate differences, and rate ratios by category of county-level ABSMs. To illustrate the performance of the method at finer levels of geographic aggregation, we analyze data on (a) confirmed cases in Illinois zip codes and (b) positive test results in New York City ZIP codes with ZIP code level ABSMs. We detect stark gradients though complex gradients in COVID-19 deaths by county-level ABSMs, with dramatically increased risk of death observed among residents of the most disadvantaged counties. Monotonic socioeconomic gradients in Illinois confirmed cases and New York City positive tests by ZIP code level ABSMs were also observed. We recommend that public health departments use these straightforward cost-effective methods to report on social inequities in COVID-19 outcomes to provide an evidence base for policy and resource allocation.
Now Published in Journal...
Journal of Public Health Management & Practice: “Revealing the Unequal Burden of COVID-19 by Income, Race/Ethnicity, and Household Crowding: US County Versus Zip Code Analyses.”
Title: COVID-19 and the unequal surge in mortality rates in Massachusetts, by city/town and ZIP Code measures of poverty, household crowding, race/ethnicity,and racialized economic segregation
Working paper #: Volume 19, No. 2
Author(s): Jarvis Chen, Pamela Waterman, and Nancy Krieger
Despite the paucity of adequate data on race/ethnicity – and no data on socioeconomic position – in US national data on COVID-19 mortality, both investigative journalism and some state and local health departments are beginning to document evidence of the greater mortality burden of COVID-19 on communities of color and low-income communities. To date, such documentation has been in relation to deaths categorized as due to COVID-19. However, in a context when assignment of cause of death to COVID-19 is dynamic and incomplete, given developing scientific evidence, one important strategy for assessing differential impacts of COVID-19 is that of evaluating the overall excess of deaths, as compared to the same time period in prior years. We employ this approach in this working paper and provide a transparent, easy-to-replicate methodology that relies on the reported data (i.e., no model-based estimates or complex modeling assumptions) and that can be readily used by any local or state health agency to monitor the social patterning of excess mortality rates during the COVID-19 pandemic. Key findings are that the surge in excess death rates, both relative and absolute, was evident starting in early April, and was greater in city/towns and ZCTAs with higher poverty, higher household crowding, higher percentage of populations of color, and higher racialized economic segregation. These data provide the backbone to a story that is being published in the Boston Globe, with this Working Paper released following publication of this story (on May 9, 2020), available at:
Now Published in Journal...
Title: The unequal toll of COVID-19 mortality by age in the United States: Quantifying racial/ethnic disparities
Working paper #: Volume 19, No. 3
Author(s): Mary T. Bassett, MD, MPH, Jarvis T. Chen, ScD, and Nancy Krieger, PhD
Importance: Excess COVID-19 mortality has been described among Non-Hispanic Blacks (NHB), Hispanics and Non-Hispanic American Indians/Alaska Natives (NHAIAN), compared to non-Hispanic Whites (NHW), but not in relation to age at death. Recent release of national COVID-19 deaths by racial/ethnic group now permit analysis of age-specific mortality rates.
Objective: To examine variation in age-specific mortality rates by racial/ethnicity and calculate its impact using Years of Potential Life Lost (YPLL).
Design: This is a descriptive study using the most recently publicly available data on COVID-19 deaths, with population data drawn from the US Census
Setting: United States
Participants: All persons for whom there were reported deaths, COVID-19 deaths and reported racial/ethnicity February 1, 2020-May 20, 2020
Results: Age-standardized rate ratios relative to NHW were 3.6 (95% CI 3.5, 3.7) for NHB, 2.6 95% CI 2.4, 2.7) for Hispanics, 1.2 (0.8, 1.6) for NHAIAN, and 1.7 (1.6, 1.9) for NHAPI. By contrast, NHB rate ratios relative to NHW were as high as 7.3 (95% CI 5.6, 9.5) for 25-34 year old, 9.0 (95% CI 7.6, 10.8) for 35-44 year old, and 6.9 (95% CI 6.3, 7.6) for 45-54 year old. Even at older ages, NHB rate ratios were between 1.9 and 5.7. Similarly, rate ratios for Hispanics vs. NHW were 5.5 (95% CI 4.2, 7.2), 7.9 (95% CI 6.7, 9.3), and 5.8 (95% CI 5.3, 6.3) for corresponding age strata, with remaining rate ratios ranging from 1.4 to 4.1. Rate ratios for NHAIAN were similarly high, ranging from 1.4 to 8.2 over ages 25-75, and only dipping below 1.0 for age 75-84 and 85+. Among NHAPI, rate ratios ranged from 2.2 to 2.4 for ages 25-75 and were 1.6 and 1.2 for age 75-84 and 85+ respectively. As a consequence, more years of potential life lost were experienced by African Americans and Latinos than whites, although the white population is 3-4 fold larger.
Conclusion/Relevance: This analysis makes clear the importance of examining age-specific mortality rates and underscore how age standardization can obscure extreme variations within age strata. Data that permit age-specific analyses should be routinely publicly available.
Now Published in Journal...
Title: Visualizing the lagged connection between COVID-19 cases and deaths in the United States: An animation using per capita state-level data (January 22, 2020 – July 8, 2020)
Working paper #: Volume 19, No. 4
Author(s): Christian C. Testa, BS, Nancy Krieger, PhD, Jarvis T. Chen, ScD, and William P. Hanage, PhD
Data visualizations of the COVID-19 pandemic in the United States often have presented case and death rates by state in separate visualizations making it difficult to discern the temporal relationship between these two epidemiological metrics. By combining the COVID-19 case and death rates into a single visualization we have provided an intuitive format for depicting the relationship between cases and deaths. Moreover, by using animation we have made the temporal lag between cases and subsequent deaths more obvious and apparent. This work helps to inform expectations for the trajectory of death rates in the United States given the recent surge in case rates.
Working paper #: Volume 20, No. 1
Author(s): Nancy Krieger, PhD, Christian C. Testa, BS, and Jarvis T. Chen, ScD
We report novel data on persistence of missing racial/ethnic data for COVID-19 cases in the United States, despite a federal policy that went into effect on June 4, 2020, which stated reporting of such data would be mandatory, effective by no later than August 1, 2020. To our knowledge, no report has documented whether or not US federal agencies or states are in compliance with this regulation.
Our key finding, based on publicly available data at the CDC website, is that racial/ethnic data was missing for fully 43% of the 422,057 COVID-19 cases recorded between August 28, 2020 and September 16, 2020.
Publicly available data at the COVID-19 Racial Data Tracker likewise indicates that as of September 13, 2020, 37.5% of the recorded 6,448,573 cases were missing data on race, and among states, the percent missing ranged from 0% to 100%, with a median value of 21%.
These findings suggest that compliance with regulations to report data on race/ethnicity for US COVID-19 cases is inadequate and continues to hamper understanding of and efforts to mitigate racial/ethnic inequities in COVID-19.
Now Published in Journal...
The Lancet (correspondence): “US racial and ethnic data for COVID-19 cases: still missing in action”
Working paper #: Volume 20, No. 2
Author(s): W. P. Hanage, C. Testa , J. T. Chen, L. Davis, E. Pechter, M. Santillana, and N. Krieger
The United States (US) has been among those nations most severely affected by the first—and subsequent—phases of the pandemic of COVID-19 disease caused by SARS-CoV-2. With only 4% of the worldwide population, the US has seen about 22% of COVID-19 deaths. Despite formidable advantages in resources and expertise, presently the per capita mortality rate is over 585/million, respectively 2.4 and 5 times higher compared to Canada and Germany. As we enter Fall 2020, the US is enduring ongoing outbreaks across large regions of the country. Moreover, within the US, an early and persistent feature of the pandemic has been the disproportionate impact on populations already made vulnerable by racism and dangerous jobs, inadequate wages, and unaffordable housing, and this is true for both the headline public health threat and the additional disastrous economic impacts. In this article we assess the impact of missteps by the Federal Government in three specific areas: the introduction of the virus to the US and the establishment of community transmission; the lack of national COVID-19 workplace standards and lack of personal protective equipment (PPE) for workplaces as represented by complaints to the Occupational Safety and Health Administration (OSHA) which we find are correlated with deaths 17 days later (=0.845); and the total excess deaths in 2020 to date, which already total more than 230,000 and exhibit severe inequities in race/ethnicity including among younger age groups.
Working paper #: Volume 20, No. 3
Author(s): N. Krieger, J. T. Chen, C. Testa, and W. P. Hanage
COVID-19 doesn’t care who you are or what you believe. It does not respect political ideology or partisan rancor. As far as the virus SARS-COV-2 is concerned, all that matters is opportunities for exposure and transmission: are you available as a potential host – or not. For people, what matters are the actions you are able – or not able or not permitted – to take to protect yourself, your family, and your community, from exposure to the virus. True, COVID-19 is a global pandemic – but it is simultaneously as local and as intimate as the contacts you have where you live, work, travel, and the public spaces you visit. The maps of the changing political geography of COVID-19 make this vividly clear. From mid-March to June, the excess death rates were highest in states leaning Democratic, and the more strongly they tilted in that direction, the greater the excess. However, in mid-July, the pattern reversed, with the burden of excess death rates growing highest in Republican leaning states. As we enter the fall, the rates of excess deaths are now highest in the states that lean most Republican. Reducing risk of exposure is key.