Well and Good

Kevin Lewis

June 20, 2011

Estimated Deaths Attributable to Social Factors in the United States

Sandro Galea et al.
American Journal of Public Health, forthcoming

Objectives: We estimated the number of deaths attributable to social factors in the United States.

Methods: We conducted a MEDLINE search for all English-language articles published between 1980 and 2007 with estimates of the relation between social factors and adult all-cause mortality. We calculated summary relative risk estimates of mortality, and we obtained and used prevalence estimates for each social factor to calculate the population-attributable fraction for each factor. We then calculated the number of deaths attributable to each social factor in the United States in 2000.

Results: Approximately 245000 deaths in the United States in 2000 were attributable to low education, 176000 to racial segregation, 162000 to low social support, 133000 to individual-level poverty, 119000 to income inequality, and 39000 to area-level poverty.

Conclusions: The estimated number of deaths attributable to social factors in the United States is comparable to the number attributed to pathophysiological and behavioral causes. These findings argue for a broader public health conceptualization of the causes of mortality and an expansive policy approach that considers how social factors can be addressed to improve the health of populations.


"Macho Men" and Preventive Health Care: Implications for Older Men in Different Social Classes

Kristen Springer & Dawne Mouzon
Journal of Health and Social Behavior, June 2011, Pages 212-227

The gender paradox in mortality - where men die earlier than women despite having more socioeconomic resources - may be partly explained by men's lower levels of preventive health care. Stereotypical notions of masculinity reduce preventive health care; however, the relationship between masculinity, socioeconomic status (SES), and preventive health care is unknown. Using the Wisconsin Longitudinal Study, the authors conduct a population-based assessment of masculinity beliefs and preventive health care, including whether these relationships vary by SES. The results show that men with strong masculinity beliefs are half as likely as men with more moderate masculinity beliefs to receive preventive care. Furthermore, in contrast to the well-established SES gradient in health, men with strong masculinity beliefs do not benefit from higher education and their probability of obtaining preventive health care decreases as their occupational status, wealth, and/or income increases. Masculinity may be a partial explanation for the paradox of men's lower life expectancy, despite their higher SES.


The Benefits To All Of Ensuring Equal And Timely Access To Influenza Vaccines In Poor Communities

Bruce Lee et al.
Health Affairs, June 2011, Pages 1141-1150

When influenza vaccines are in short supply, allocating vaccines equitably among different jurisdictions can be challenging. But justice is not the only reason to ensure that poorer counties have the same access to influenza vaccines as do wealthier ones. Using a detailed computer simulation model of the Washington, D.C., metropolitan region, we found that limiting or delaying vaccination of residents of poorer counties could raise the total number of influenza infections and the number of new infections per day at the peak of an epidemic throughout the region-even in the wealthier counties that had received more timely and abundant vaccine access. Among other underlying reasons, poorer counties tend to have high-density populations and more children and other higher-risk people per household, resulting in more interactions and both increased transmission of influenza and greater risk for worse influenza outcomes. Thus, policy makers across the country, in poor and wealthy areas alike, have an incentive to ensure that poorer residents have equal access to vaccines.


Does inequality in health impede economic growth?

Michael Grimm
Oxford Economic Papers, July 2011, Pages 448-474

This paper investigates the effects of inequality in health on economic growth in low and middle income countries. The empirical part of the paper uses an original cross-national panel data set covering 62 low and middle income countries over the period 1985 to 2007. I find a substantial and relatively robust negative effect of health inequality on income levels and income growth controlling for life expectancy, country and time fixed-effects and a large number of other effects that have been shown to matter for growth. The effect also holds if health inequality is instrumented to circumvent a potential problem of reverse causality. Hence, reducing inequality in the access to health care and to health-related information can make a substantial contribution to economic growth.


Fuel Economy, Car Class Mix, and Safety

Mark Jacobsen
American Economic Review, May 2011, Pages 105-109

Fuel economy standards change the composition of the vehicle fleet, potentially influencing accident fatality risks. I estimate the direction and magnitude of this impact, introducing a correction for selection on driver behavior. A policy application using my new estimates shows that the present distinction between light trucks and cars in fuel economy rules has very negative consequences for overall safety: Each MPG increment to the standard results in an additional 150 fatalities per year in expectation. My correction for selection is pivotal in this finding. I then demonstrate a simple alternative regulation that can produce near-zero changes in accident fatalities.


Criminal Prosecution and Human Immunodeficiency Virus-Related Risky Behavior

Adeline Delavande, Dana Goldman & Neeraj Sood
Journal of Law and Economics, November 2010, Pages 741-782

We examine the consequences of prosecuting people who are human immunodeficiency virus (HIV) positive and expose others to the infection. We show that the effect of such prosecutions on the spread of HIV is a priori ambiguous. The prosecutions deter unsafe sex. However, they also create incentives for having sex with partners who are more promiscuous, which consequently increases the spread of HIV. We test these predictions and find that such prosecutions are associated with a reduction in the number of partners, an increase in safe sex, and an increase in sex with prostitutes. We estimate that doubling the prosecution rate could decrease the total number of new HIV infections by one-third over a 10-year period.


The impact of the National School Lunch Program on child health: A nonparametric bounds analysis

Craig Gundersen, Brent Kreider & John Pepper
Journal of Econometrics, forthcoming

Children in households reporting the receipt of free or reduced-price school meals through the National School Lunch Program (NSLP) are more likely to have negative health outcomes than observationally similar nonparticipants. Assessing causal effects of the program is made difficult, however, by missing counterfactuals and systematic underreporting of program participation. Combining survey data with auxiliary administrative information on the size of the NSLP caseload, we extend nonparametric partial identification methods to account for endogenous selection and nonrandom classification error in a single framework. Similar to a regression discontinuity design, we introduce a new way to conceptualize the monotone instrumental variable (MIV) assumption using eligibility criteria as monotone instruments. Under relatively weak assumptions, we find evidence that receipt of free and reduced-price lunches improves the health outcomes of children.


Racial Disparities in the Cognition-Health Relationship

Owen Thompson
Journal of Health Economics, forthcoming

This paper investigates how the association between cognitive achievement and self-rated health in middle age differs by race, and attempts to explain these differences. The role of cognition in health determination has received only limited empirical attention, and even less is known about how race may affect this relationship. Using data from the NLSY, I find that while whites with higher cognitive achievement scores tend to report substantially better general health, this relationship is far weaker or wholly absent among blacks. Further tests suggest that about 35% of this racial difference can be explained by behavioral decisions during adulthood, and that another portion of the disparity may trace back to prenatal and early childhood experiences. The paper closes by noting that its results are broadly consistent with explanations of the racial health gap that emphasize entrenched forms of racial discrimination.


A Life Course Perspective on Child Health, Cognition and Occupational Skill Qualifications in Adulthood: Evidence from a British Cohort

Margot Jackson
Social Forces, September 2010, Pages 89-116

Existing research rarely examines the social consequences of poor childhood health from a longitudinal perspective. Using data from the British National Child Development Study, I follow a cohort from before birth through middle age to examine whether children's health limitations before and during the educational process predict occupational skill in mid-adulthood, and whether negative consequences are strongest for children in persistently poor health. I also examine whether differences in achievement explain the observed associations, and at what point during the schooling process performance begins to play a large explanatory role. Poor health is strongly negatively related to qualifications in adulthood, particularly for children in persistently poor health. These associations are largely explained by differences in performance early in children's academic careers, before the first important transition point. The relationship between prenatal maternal smoking and mid-adulthood qualifications is more persistent. This article demonstrates that a static conceptualization of childhood health is inadequate to fully understand the dynamic process through which social status and health over the course of childhood have long-run consequences for the adult life course.


Anatomy of a health scare: Education, income and the MMR controversy in the UK

Dan Anderberg, Arnaud Chevalier & Jonathan Wadsworth
Journal of Health Economics, May 2011, Pages 515-530

The measles, mumps and rubella (MMR) controversy provides an interesting case where, for a short period of time, research publicized in the media, suggested a potential risk of serious side-effects associated with the vaccine, where there was also a sharp behavioral response from the public, and where the initial information was subsequently overturned. We consider the controversy from the perspective of health inequalities and the assimilation of information, focusing on whether and how vaccine uptake behavior in the wake of the controversy differed among groups of parents by education and income. Using panel data on the variation in the uptake of the MMR, and other childhood immunizations, across local Health Authority areas we find that the uptake rate of the MMR declined faster in areas where a larger fraction of parents had stayed in education past the age of 18 than in areas with less educated parents. We also find that the same areas reduced their relative uptake of other uncontroversial childhood immunizations, suggesting a "spillover" effect. Using a supplementary data source we find evidence of a corresponding positive income effect, indicating that wealthier parents avoided the MMR dilemma by purchasing single vaccines.


Early childhood socioeconomic status is associated with circulating interleukin-6 among mid-life adults

Judith Carroll, Sheldon Cohen & Anna Marsland
Brain, Behavior, and Immunity, forthcoming

It is proposed that socioeconomic conditions in early childhood effect immune programming, with poorer conditions resulting in adult phenotypes that are prone to inflammation. Recent evidence supports this possibility, showing an inverse association of childhood SES with adult markers of systemic inflammation. In this study, we further investigate this association, extending prior studies to include an examination of multiple indices of SES across distinct periods of childhood. Subjects were 112 men and women, 40-60 years of age (88.6% Caucasian). Childhood SES was indexed by a composite of three indicators of parental wealth (parental home and vehicle ownership, and number of bedrooms per child in the family home) averaged across 2 year periods of childhood between 1 and 18 years old. Higher adult serum concentrations of interleukin (IL)-6 were associated with lower SES in early childhood (years 1-2) (β = -.05, p < .05), associations that were independent of adult age, personal income, educational attainment, gender, race, body mass index, and physical activity. These associations support recent suggestions that the early environment may program immune phenotypes that contribute to disease risk.


The causal relationship between education, health and health related behaviour: Evidence from a natural experiment in England

Nils Braakmann
Journal of Health Economics, forthcoming

I exploit exogenous variation in the likelihood to obtain any sort of educational qualification between January- and February-born individuals for 13 academic cohorts in England. For these cohorts compulsory schooling laws interacted with the timing of the CSE and O-level exams to change the probability of obtaining a qualification by around2 to 3 percentage points. I then use data on individuals born in these two months from the British Labour Force Survey and the Health Survey for England to investigate the effects of education on health using being February-born as an instrument for education. The results indicate neither an effect of education on various health related measures nor an effect on health related behaviour, e.g., smoking, drinking or eating various types of food.


Framing flu prevention - An experimental field test of signs promoting hand hygiene during the 2009-2010 H1N1 pandemic

John Updegraff et al.
Health Psychology, May 2011, Pages 295-299

Objective: During the 2009-2010 H1N1 flu pandemic, many institutions installed alcohol-based hand sanitizer dispensers in public settings in an effort to prevent the spread of the virus. Yet, usage of these dispensers remained low.

Method: Point-of-use reminder signs were designed to emphasize four theoretically grounded health beliefs: perceived susceptibility, social norms, consequences of the behavior framed as gains, and consequences of the behavior framed as losses. From October 2009 to March 2010, 58 sanitizer dispensers in public buildings were randomly assigned to have one of the four signs placed next to it, and dispenser usage was continually monitored.

Results: All signs were associated with greater sanitizer usage compared to no sign. The gain-framed sign was associated with greatest usage (66% over no sign). Signs emphasizing susceptibility to H1N1 were associated with the lowest usage (41% over no sign). Although usage declined over time and closely mirrored trends in public interest about H1N1, the influence of the signs was not dependent on degree of public interest.

Conclusion: This experimental field study shows how simple, theoretically grounded signs can serve as cues to action in promoting the adoption of preventive behaviors. Gain-framed signage is particularly effective in promoting hand hygiene in a flu pandemic.


Travel Patterns in China

Tini Garske et al.
PLoS ONE, February 2011, e16364

The spread of infectious disease epidemics is mediated by human travel. Yet human mobility patterns vary substantially between countries and regions. Quantifying the frequency of travel and length of journeys in well-defined population is therefore critical for predicting the likely speed and pattern of spread of emerging infectious diseases, such as a new influenza pandemic. Here we present the results of a large population survey undertaken in 2007 in two areas of China: Shenzhen city in Guangdong province, and Huangshan city in Anhui province. In each area, 10,000 randomly selected individuals were interviewed, and data on regular and occasional journeys collected. Travel behaviour was examined as a function of age, sex, economic status and home location. Women and children were generally found to travel shorter distances than men. Travel patterns in the economically developed Shenzhen region are shown to resemble those in developed and economically advanced middle income countries with a significant fraction of the population commuting over distances in excess of 50 km. Conversely, in the less developed rural region of Anhui, travel was much more local, with very few journeys over 30 km. Travel patterns in both populations were well-fitted by a gravity model with a lognormal kernel function. The results provide the first quantitative information on human travel patterns in modern China, and suggest that a pandemic emerging in a less developed area of rural China might spread geographically sufficiently slowly for containment to be feasible, while spatial spread in the more economically developed areas might be expected to be much more rapid, making containment more difficult.


Are There Adverse Consequences to Being a Sibling of a Person With a Disability? A Propensity Score Analysis

Susan Neely-Barnes & Carolyn Graff
Family Relations, July 2011, Pages 331-341

This study examined whether siblings of children with disabilities have increased mental health problems, behavioral difficulties, or greater mental health service use as compared to siblings of children without disabilities. Data come from the 2006 National Health Interview Survey. Propensity score matching was used to complete the analysis. Twelve siblings and family demographic characteristics were used to create the propensity score. Hierarchical greedy matching without replacement was used to match siblings. Prior to the match, significant differences were present between sibling groups on all outcome variables. After the match, no significant differences remained. Effect sizes were compared and were smaller postmatch for all the three measured outcomes. Findings suggest that differences in siblings' mental health are not likely due to the presence of a brother or sister with a disability, but it is more likely that the co-occurring risk factors (e.g., living in a lower income household) contribute to the observed sibling differences.


Genetic Lotteries within Families

Jason Fletcher
Journal of Health Economics, forthcoming

Drawing on findings from the biomedical literature, this paper introduces the idea that specific exogenously inherited differences in the genetic code between full biological siblings can be used to test within-family estimators and potentially improve our understanding of economic relationships. These points are illustrated with an application to identify the causal impact of several poor health conditions on academic outcomes. We present evidence that family fixed effects estimators by themselves cannot fully account for the endogeneity of poor health when estimating education production functions. Further, our analysis elucidates the situations under which genetic markers can serve as instrumental variables for specific health conditions.


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