Instructor, Medicine - General Medical Disciplines
The current literature in social epidemiology and public health suggests that low financial savings has an unsurprising negative relationship with subjective well-being, and increases the odds of making visits to a healthcare provider, receiving a chronic disease diagnosis, and experiencing medical disability. Earn.org is a community-based non-profit based in San Francisco with a mission to help low-income workers build lifelong savings habits and financial capability. The organization is one of the largest providers of "goal-based savings accounts" or "matched savings accounts" in the US. The investigators propose to conduct a randomized controlled trial to determine the health effects of Earn's savings program. Through this trial, the investigators will test three principal hypotheses: (1) Participants in the Earn account, as compared to a control group, are hypothesized to demonstrate improved scores on mental health scales assessing depression and anxiety. (2) Participants in the Earn account, as compared to a control group, are hypothesized to experience lower odds of harmful behaviors associated with stress, specifically tobacco and alcohol abuse. The investigators hypothesize that the effect on behaviors will be of smaller effect size, and more delayed, than the effect on mental health outcomes, judging from similar effects observed in the micro-credit literature. (3) The mediating variables between Earn account participation and beneficial health outcomes will include increased optimism and internal locus of control.
Stanford is currently not accepting patients for this trial. For more information, please contact Sanjay Basu, (415) 881 - 7030.
Objectives. We examined the mental health effects of the Great Recession of 2008 to 2009 on workers who remained continuously employed and insured. Methods. We examined utilization trends for mental health services and medications during 2007 to 2012 among a panel of workers in the 25 largest plants, located in 15 states, of a US manufacturing firm. We used piecewise regression to compare trends from 2007 to 2010 in service and medication use before and after 2009, the year of mass layoffs at the firm and the peak of the recession. Our models accounted for changes in county-level unemployment rates and individual-level fixed effects. Results. Mental health inpatient and outpatient visits and the yearly supply of mental health-related medications increased among all workers after 2009. The magnitude of the increase in medication usage was higher for workers at plants with more layoffs. Conclusions. The negative effects of the recession on mental health extend to employed individuals, a group considered at lower risk of psychological distress.
View details for DOI 10.2105/AJPH.2014.302219
View details for Web of Science ID 000351922500035
While the negative effects of unemployment have been well studied, the consequences of layoffs and downsizing for those who remain employed are less well understood. This study uses human resources and health claims data from a large multi-site fully insured aluminum company to explore the health consequences of downsizing on the remaining workforce. We exploit the variation in the timing and intensity of layoff to categorize 30 plants as high or low layoff plants. Next, we select a stably employed cohort of workers with history of health insurance going back to 2006 to 1) describe the selection process into layoff and 2) explore the association between the severity of plant level layoffs and the incidence of four chronic conditions in the remaining workforce. We examine four health outcomes: incident hypertension, diabetes, asthma/COPD and depression for a cohort of approximately 13,000 employees. Results suggest that there was an increased risk of developing hypertension for all workers and an increased risk of developing diabetes for salaried workers that remain at the plants with the highest level of layoffs. The hypertension results were robust to a several specification tests. In addition, the study design selected only healthy workers, therefore our estimates are likely to be a lower bound and suggest that adverse health consequences of the 2007-2009 recession may have affected a broader proportion of the population than previously expected.
View details for DOI 10.1016/j.socscimed.2013.04.027
View details for Web of Science ID 000322858200012
Previous studies show a variety of negative health consequences for the remaining workforce after downsizing events. This study examined self-reported work stress from 2009-2012 in the context of a large multi-site aluminum manufacturing company that underwent severe downsizing in 2009.This study examined the association between work stress and working at a work site that underwent severe downsizing. We assessed the level of downsizing across thirty plants in 2009 and categorized seven as having undergone severe downsizing. We linked plant-level downsizing information to individual workers' responses to an annual work engagement survey, which included three work stress questions. From 2009 to 2012 over 14, 000 employees were asked about their experience of work stress. Though the surveys were anonymous, the surveys captured employees' demographic and employment characteristic as well as plant location. We used hierarchical logistic regressions to compare responses of workers at severely downsized plants to workers at all other plant while controlling for demographic and plant characteristics. Responses to the work stress questions and one control question were examined.In all yearly surveys salaried workers consistently reported having more work stress than hourly workers. There was no differential in work stress for workers at severely downsized plants in 2009. In 2010 to 2012, salaried workers who remained at severely downsized plants reported significantly higher work stress than salaried workers at all other plants across multiple work stress questions. Examination of the 2006 survey confirmed that there were no pre-existing differences in work stress among salaried employees working at plants that would eventually experience severe downsizing. In addition, there was no difference in responses to the control question at severely downsized plants.Salaried workers at plants with high layoffs experienced more work stress after 2009 than their counterparts at non-high layoff plants. Increased work stress is important to monitor and may be a mediating pathway through which the external economic environment leads to adverse health outcomes.
View details for DOI 10.1186/1471-2458-13-929
View details for PubMedID 24093476
We examined how state characteristics in early life are associated with individual chronic disease later in life.We assessed early-life state of residence using the first 3 digits of social security numbers from blue- and white-collar workers from a US manufacturing company. Longitudinal data were available from 1997 to 2012, with 305 936 person-years of observation. Disease was assessed using medical claims. We modeled associations using pooled logistic regression with inverse probability of censoring weights.We found small but statistically significant associations between early-state-of-residence characteristics and later life hypertension, diabetes, and ischemic heart disease. The most consistent associations were with income inequality, percentage non-White, and education. These associations were similar after statistically controlling for individual socioeconomic and demographic characteristics and current state characteristics.Characteristics of the state in which an individual lives early in life are associated with prevalence of chronic disease later in life, with a strength of association equivalent to genetic associations found for these same health outcomes.
View details for DOI 10.2105/AJPH.2014.302547
View details for Web of Science ID 000362950400058
Investigators across many fields often struggle with how best to capture an individual's overall health status, with options including both subjective and objective measures. With the increasing availability of "big data," researchers can now take advantage of novel metrics of health status. These predictive algorithms were initially developed to forecast and manage expenditures, yet they represent an underutilized tool that could contribute significantly to health research. In this paper, we describe the properties and possible applications of one such "health risk score," the DxCG Intelligence tool.We link claims and administrative datasets on a cohort of U.S. workers during the period 1996-2011 (N = 14,161). We examine the risk score's association with incident diagnoses of five disease conditions, and we link employee data with the National Death Index to characterize its relationship with mortality. We review prior studies documenting the risk score's association with other health and non-health outcomes, including healthcare utilization, early retirement, and occupational injury.We find that the risk score is associated with outcomes across a variety of health and non-health domains. These examples demonstrate the broad applicability of this tool in multiple fields of research and illustrate its utility as a measure of overall health status for epidemiologists and other health researchers.
View details for DOI 10.1371/journal.pone.0126054
View details for PubMedID 25951622
A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6 months, during which participants receive a $5 incentive (£3.2, €4.5) for every month they save $20 in their account (£12.8, €18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6 months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.Identifier NCT02185612; Pre-results.
View details for DOI 10.1136/bmjopen-2015-009366
View details for PubMedID 26443663
Rapid tests for malaria are being distributed through vendors to individual patients, presenting the dilemma of determining how individuals are incentivized to pursue testing for malaria, versus the traditional approach of presumptively treating fevers with antimalarial drugs.We incorporated testing and treatment data from 6 African countries into a dynamic model of malaria transmission and nonmalarial causes of fever to investigate how variations in the epidemiologic risk of malaria and the prices of rapid diagnostic tests (RDTs) and treatments affect testing and treatment choices from the perspective of febrile patients, public health officials, and drug shop owners. In environments falling below a critical threshold infection rate (entomological inoculation rate) of 282 for patients older than 5 years (95% confidence interval [CI]: 275-289) or 300 for 0- to 5-year-olds (95% CI: 203-307), testing was more beneficial than presumptive therapy in terms of health and financial costs to patients. Infection and cost conditions generally aligned the best patient-level strategy with the best public health strategy to minimize an overall population's morbidity and mortality from both malaria and nonmalarial causes of fever. However, the infection and cost conditions of very high malaria transmission settings did not align patient interests or public health interests with the interests of private drug shop owners. In such settings, a further lowering of testing prices may realign the interests of all 3 parties.A threshold transmission rate exists under which malaria testing confers more health and financial benefits to patients than presumptive treatment. Studying local transmission rates and testing and treatment costs may facilitate an approach to align the interests of individual patients, public health officials, and distributors of tests and therapies.
View details for DOI 10.1177/0272989X14533609
View details for PubMedID 24829277
The World Health Organization now recommends parasitological confirmation for malaria case management. Rapid diagnostic tests (RDTs) for malaria are an accurate and simple diagnostic to confirm parasite presence in blood. However, where they have been deployed, adherence to RDT results has been poor, especially when the test result is negative. Few studies have examined adherence to RDTs distributed or purchased through the private sector.The Rapid Examination of Malaria and Evaluation of Diagnostic Information (REMEDI) study assessed the acceptability of and adherence to RDT results for patients seeking care from private sector drug retailers in two cities in Oyo State in south-west Nigeria. In total, 465 adult participants were enrolled upon exit from a participating drug shop having purchased anti-malaria drugs for themselves. Participants were given a free RDT and the appropriate treatment advice based on their RDT result. Short Message Service (SMS) text messages reiterating the treatment advice were sent to a randomly selected half of the participants one day after being tested. Participants were contacted via phone four days after the RDT was conducted to assess adherence to the RDT information and treatment advice.Adherence to RDT results was 14.3 percentage points (P-val <0.001) higher in the treatment group who were sent the SMS. The higher adherence in the treatment group was robust to several specification tests and the estimated difference in adherence ranged from 9.7 to 16.1 percentage points. Further, the higher adherence to the treatment advice was specific to the treatment advice for anti-malarial drugs and not other drugs purchased to treat malaria symptoms in the RDT-negative participants who bought both anti-malarial and symptom drugs. There was no difference in adherence for the RDT-positive participants who were sent the SMS.SMS text messages substantially increased adherence to RDT results for patients seeking care for malaria from privately owned drug retailers in Nigeria and may be a simple and cost-effective means for boosting adherence to RDT results if and when RDTs are introduced as a commercial retail product.
View details for DOI 10.1186/1475-2875-13-69
View details for Web of Science ID 000332775900001
View details for PubMedID 24564925
Despite policies that recommend parasitological testing before treatment for malaria, presumptive treatment remains widespread in Nigeria. The majority of Nigerians obtain antimalarial drugs from two types of for-profit drug vendors-formal and informal medicine shops-but little is known about the quality of malaria care services provided at these shops.This study seeks to (1) describe the profile of patients who seek treatment at different types of drug outlets, (2) document the types of drugs purchased for treating malaria, (3) assess which patients are purchasing recommended drugs, and (4) estimate the extent of malaria over-treatment.In urban, peri-urban, and rural areas in Oyo State, customers exiting proprietary and patent medicine vendor (PPMV) shops or pharmacies having purchased anti-malarial drugs were surveyed and tested with malaria rapid diagnostic test. A follow-up phone survey was conducted four days after to assess self-reported drug administration. Bivariate and multivariate regression analysis was conducted to determine the correlates of patronizing a PPMV versus pharmacy, and the likelihood of purchasing an artemisinin-combination therapy (ACT) drug.Of the 457 participants who sought malaria treatment in 49 enrolled outlets, nearly 92% had diagnosed their condition by themselves, a family member, or a friend. Nearly 60% pharmacy customers purchased an ACT compared to only 29% of PPMV customers, and pharmacy customers paid significantly more on average. Multivariate regression results show that patrons of PPMVs were younger, less wealthy, waited fewer days before seeking care, and were less likely to be diagnosed at a hospital, clinic, or laboratory. Only 3.9% of participants tested positive with a malaria rapid diagnostic test.Poorer individuals seeking care at PPMVs are more likely to receive inappropriate malaria treatment when compared to those who go to pharmacies. Increasing accessibility to reliable diagnosis should be explored to reduce malaria over-treatment.
View details for DOI 10.1371/journal.pone.0110361
View details for PubMedID 25333909
View details for DOI 10.1186/1471-2458-13-921
Prior research has shown increased risk of injury for female employees compared to male employees after controlling for job and tasks, but have not explored whether this increased risk might be moderated by manager gender. The gender of one's manager could in theory affect injury rates among male and female employees through their managers' response to an employee's psychosocial stress or through how employees differentially report injuries. Other explanations for the gender disparity in injury experience, such as ergonomic factors or differential training, are unlikely to be impacted by supervisor gender. This study seeks to explore whether an employee's manager's gender modifies the effect of employee gender with regards to risk of acute injury.A cohort of employees and managers were identified using human resources and injury management data between January 1, 2002 and December 31, 2007 for six facilities of a large US aluminum manufacturing company. Cox proportional hazards models were employed to examine the interaction between employee gender and whether the employee had female only manager(s), male only manager(s), or both male and female managers on injury risk. Manager gender category was included as a time varying covariate and reassessed for each employee at the midpoint of each year.The percentage of departments with both female and male managers increased dramatically during the study period due to corporate efforts to increase female representation in management. After adjustment for fixed effects at the facility level and shared frailty by department, manager gender category does not appear to moderate the effect of employee gender (p = 0.717). Manager category was not a significant predictor (p = 0.093) of time to first acute injury. Similarly, having at least one female manager did not modify the hazard of injury for female employees compared to males (p = 0.899) and was not a significant predictor of time to first acute injury (p = 0.601).Prior findings suggest that female manufacturing employees are at higher risk for acute injury compared to males; this analysis suggests that this relationship is not affected by the gender of the employee's manager(s).
View details for DOI 10.1186/1471-2458-13-1053
View details for PubMedID 24207014
Policy makers have speculated that one of the economic benefits of malaria elimination includes increases in foreign direct investment, particularly tourism.This study examines the empirical relationship between the demand for travel and malaria cases in two countries with large tourism industries around the time in which they carried out malaria-elimination campaigns. In Mauritius, this analysis examines historical, yearly tourist arrivals and malaria cases from 1978-1999, accounting for the background secular trend of increasing international travel. In Dominican Republic, a country embarking upon malaria elimination, it employs a time-series analysis of the monthly, international tourist arrivals from 1998-2010 to determine whether the timing of significant deviations in tourist arrivals coincides with malaria outbreaks.While naïve relationships exist in both cases, the results show that the relationships between tourist arrivals and malaria cases are relatively weak and statistically insignificant once secular confounders are accounted for.This suggests that any economic benefits from tourism that may be derived from actively pursuing elimination in countries that have high tourism potential are likely to be small when measured at a national level. Rather, tourism benefits are likely to be experienced with greater impact in more concentrated tourist areas within countries, and future studies should seek to assess these relationships at a regional or local level.
View details for DOI 10.1186/1475-2875-11-244
View details for Web of Science ID 000309741300001
View details for PubMedID 22839351
Despite the large number of studies, mostly in developed economies, there is limited consensus on the health effects of inequality. Recently a related literature has examined the relationship between relative deprivation and health as a mechanism to explain the economic inequality and health relationship. This study evaluates the relationship between mortality and economic inequality, as measured by area-level Gini coefficients, as well as the relationship between mortality and relative deprivation, in the context of a middle-income country, Costa Rica. We followed a nationally representative prospective cohort of approximately 16,000 individuals aged 30 and over who were randomly selected from the 1984 census. These individuals were then linked to the Costa Rican National Death Registry until Dec. 31, 2007. Hazard models were used to estimate the relative risk of mortality for all-cause and cardiovascular disease mortality for two indicators: canton-level income inequality and relative deprivation based on asset ownership. Results indicate that there was an unexpectedly negative association between canton income inequality and mortality, but the relationship is not robust to the inclusion of canton fixed-effects. In contrast, we find a positive association between relative deprivation and mortality, which is robust to the inclusion of canton fixed-effects. Taken together, these results suggest that deprivation relative to those higher in a hierarchy is more detrimental to health than the overall dispersion of the hierarchy itself, within the Costa Rican context.
View details for DOI 10.1016/j.socscimed.2011.10.034
View details for Web of Science ID 000300809200008
View details for PubMedID 22240449
The controversy regarding the direct relationship between income distribution and health remains unresolved. Empirical evidence has often failed to advance our understanding because in the countries studied there was limited ability to distinguish hypotheses. This study examines the relation between inequality and mortality in the context of Costa Rica. Costa Rica's unique social and political structure makes confounding through resource and political channels less likely, thus any effects would work predominantly through direct psychosocial channels. Using mortality data extracted from the Vital Statistics Registry, we evaluate the longitudinal relations between lagged and contemporaneous income inequality and cause-specific mortality in Costa Rica from 1995 to 2005. For those aged 15-60, results indicate that there is a significant adverse relation between increases in lagged inequality and mortality from liver disease, and marginal adverse relations with mortality from diabetes and suicide. For those aged 60 and over, there is a limited evidence of a relation between inequality and health. These results suggest increases in inequality may impact health behavior of the working aged population in Costa Rica.
View details for DOI 10.1016/j.healthplace.2011.07.006
View details for Web of Science ID 000296671500009
View details for PubMedID 21873102
Iran experienced a dramatic decline in fertility from 1984 to 2001, which was most rapid in rural areas. Although many attribute the decline to the government's active participation in providing family planning services, most services were provided after the initial fertility decline that took place after 1984. We assess the extent to which timing of exposure to basic healthcare is related to fertility outcomes. We estimate the association between a woman's age of exposure to a health house (clinic) and number of children, using the 2001 Iranian Household Expenditure and Income Survey and the 2006 Iranian Census, and the location and dates of operation for each rural health house. We also look at the probability of a woman's giving birth one year after a clinic opened in her village. We use Poisson and logistic multivariate regressions and we control for individual, household, and village characteristics. Exposure to a health house in a woman's most fertile years (20-34) is associated with an 18 percent decrease in number of children ever born relative to those exposed after age 40. This negative association gets progressively stronger as length of exposure increases. Our findings suggest that early exposure to health services in rural areas contributed to Iran's fertility decline.
View details for DOI 10.1111/j.1728-4465.2011.00274.x
View details for Web of Science ID 000295090600001
View details for PubMedID 21972665
Attention-deficit hyperactivity disorder (ADHD) diagnostic prevalence and medication use vary across U.S. census regions, but little is known about state-level variation. The purpose of this study was to estimate this variation across states and examine whether a state's health care provider characteristics and education policies are associated with this variation.Logistic regression models were estimated with 69,505 children aged four to 17 from the state-stratified and nationally representative 2003 National Survey of Children's Health, conducted by the Centers for Disease Control and Prevention.Diagnostic prevalence was higher in the South (odds ratio [OR]=1.42, p<.001) than in the West; among children with ADHD diagnoses, medication use was higher in the South (OR=1.60, p<.01) and the Midwest (OR=1.53, p<.01) versus the West. On these measures, several states differed from the U.S. averages, including some states that, on the basis of the regional patterns found above, would not be expected to differ: Michigan had a high diagnostic prevalence; Vermont, South Dakota, and Nebraska had low diagnostic prevalences; and Connecticut, New Jersey, and Kentucky had low medication rates. Both diagnosis and medication status were associated with the number, age, and type of physicians within a state, particularly pediatricians. However, state education policies were not significantly associated with either diagnostic prevalence or medication rates.To better understand the association between a state's health care provider characteristics and both diagnostic prevalence and medication use, it may be fruitful to examine the content of provider continuing education programs, including the recommendations of major health professional organization guidelines to treat ADHD.
View details for Web of Science ID 000268537000012
View details for PubMedID 19648195
Little is known about the global use and cost of medications for attention deficit hyperactivity disorder (ADHD). Global use of ADHD medications rose threefold from 1993 through 2003, whereas global spending (2.4 billion US dollars in 2003) rose ninefold, adjusting for inflation. Per capita gross domestic product (GDP) robustly predicted use across countries, but the United States, Canada, and Australia showed significantly higher-than-predicted use. Use and spending grew in both developed and developing countries, but spending growth was concentrated in developed countries, which adopted more costly, long-acting formulations. Promoting optimal prescription and monitoring should be a priority.
View details for DOI 10.1377/hlthaff.26.2.450
View details for Web of Science ID 000244763500018
View details for PubMedID 17339673