Low-income Individuals Research Articles

Socio-ecological factors linked with changes in adults' dietary intake in Los Angeles County during the peak of the coronavirus 2019 pandemic.

Comprehensive studies examining longitudinal predictors of dietary change during the coronavirus disease 2019 pandemic are lacking. Based on an ecological framework, this study used longitudinal data to test if individual, social and environmental factors predicted change in dietary intake during the peak of the coronavirus 2019 pandemic in Los Angeles County and examined interactions among the multilevel predictors. We analysed two survey waves (e.g. baseline and follow-up) of the Understanding America Study, administered online to the same participants 3 months apart. The surveys assessed dietary intake and individual, social, and neighbourhood factors potentially associated with diet. Lagged multilevel regression models were used to predict change from baseline to follow-up in daily servings of fruits, vegetables and sugar-sweetened beverages. Data were collected in October 2020 and January 2021, during the peak of the coronavirus disease 2019 pandemic in Los Angeles County. 903 adults representative of Los Angeles County households. Individuals who had depression and less education or who identified as non-Hispanic Black or Hispanic reported unhealthy dietary changes over the study period. Individuals with smaller social networks, especially low-income individuals with smaller networks, also reported unhealthy dietary changes. After accounting for individual and social factors, neighbourhood factors were generally not associated with dietary change. Given poor diets are a leading cause of death in the USA, addressing ecological risk factors that put some segments of the community at risk for unhealthy dietary changes during a crisis should be a priority for health interventions and policy.

The illness trap: The impact of disability benefits on willingness to receive HCV treatment

Health care is assumed to be a primary good, implying that patients should always demand or accept treatments that may enhance their life expectancy and quality of life, especially if the risks associated with the treatment are low. We argue that, especially in countries with a well-developed welfare state, treating an invalidating condition may lead to opportunity costs in terms of reduced disability allowances that may represent a barrier to treatment for low-income individuals. We test this hypothesis by applying a recursive bivariate probit approach to population data from an ad hoc administrative database for Liguria (an Italian administrative region). The dataset includes data for more than 8 thousand people affected by hepatitis C Virus (HCV) infection between 2013 and 2020. After the discovery of new direct-acting antivirals (DAAs) in 2014, HCV eradication may now be possible. However, despite the national and international efforts, several patients diagnosed with HCV choose not to undergo drug therapy despite the adverse consequences for their personal health and relevant costs to the national health system. We show that five years after the implementation of the new drugs, approximately 41 % of the diagnosed population in Liguria remains untreated. This percentage increases to 64 % within the subgroup entitled to disability benefits and characterized by lower income levels. The “illness trap” effect is more substantial for older people but also low-income patients. Moreover, we find that this effect is higher in patients with an intermediate range of comorbidities; indeed, these patients are at a higher risk of losing economic benefits if they recover from HCV. These results suggest the need for healthcare policies addressing this distorting effect when designing benefit programs and granting financial benefits to patients.

Long-Term Survival and Cancer Risk in the Hepatitis C Virus-Infected Patients After Antiviral Treatment: A Nationwide Cohort Study.

Background: Exposure to the Hepatitis C virus (HCV) has been identified as one of the most critical risk factors for Hepatocellular carcinoma (HCC). Interferons and direct-acting antivirals (DAAs) have been used to treat HCV infection with high rates (95%) of prolonged virological response, a suitable safety profile, and good compliance rates. Methods: We obtained information from Taiwan's Health and Welfare Data Science Center. (HWDSC). In this observational cohort research, patients with HCV who received a diagnosis in Taiwan between 2011 and 2018 were included. Results: 78,300 untreated HCV patients were paired for age, sex, and index date with 39,150 HCV patients who received interferon or DAAs treatment. Compared to the control group, the Interferon or DAAs treatment sample has fewer low-income individuals and more hospitalization requirements. The percentage of kidney illness was reduced in the therapy group compared to the control group, but the treatment group had a greater comorbidity rate of gastric ulcers. Interferon or DAA therapy for HCV-infected patients can substantially lower mortality. All cancer diagnoses after HCV infection with interferon treatment aHR 95% CI = 0.809 (0.774-0.846), Sofosbuvir-based DAA aHR 95% CI = 1.009 (0.737-1.381) and Sofosbuvir free DAA aHR 95% CI = 0.944 (0.584-1.526) showing cancer-protective effects in the INF-treated cohort but not DAA. Conclusion: Following antiviral therapy, women appear to have a more substantial preventive impact than men against pancreatic, colorectal, and lung cancer. Interferon or DAAs treatment effect was more significant in the cirrhotic group.

Changing sustainable diet behaviours during the COVID-19 Pandemic: inequitable outcomes across a sociodemographically diverse sample of adults.

The objective of this study was to describe changes in sustainable dietary behaviours (those that support environmental, economic, and physical health) among a sample of US adults during the COVID-19 pandemic and to examine differences in changes by individuals' race/ethnicity and socioeconomic status. Therefore, a cross-sectional online survey study was conducted in April 2021 (N = 1,488, mean age = 42.7 (SD = 12.6)) receiving outpatient care from Michigan Medicine, the University of Michigan health system. Enrolment quotas were established to ensure a diverse sample-one-third of participants identified as African American/Black, one-third Hispanic/Latino, one-third White, and one-third low-income. Participants reported engaging in more behaviours that are supportive of a sustainable diet one year into the COVID-19 pandemic compared to before. This is particularly true regarding ecologically and economically sustaining behaviours such as taking fewer trips to the grocery store, increased use of home grocery delivery, increased cooking at home, and greater consumption of healthy foods. Not all behaviour changes promoted sustainable food systems; namely, the use of farmer's markets and Community Supported Agriculture (CSAs) declined. White and high-income participants were more likely than African American/Black, Hispanic/Latino, and low-income individuals to engage in ecologically and economically sustainable dietary behaviours during the pandemic. Meanwhile, African American/Black participants reported large increases in physical health sustainable dietary behaviours. To support the continuation of greater engagement with sustainable diets, policies that increase access to public transportation, limit the frequency with which consumers have groceries delivered, increase work-from-home options, and improve access for low-income populations should be prioritised.

Yolsuzluğun gelir eşitsizliği üzerindeki olumlu ve olumsuz etkileri: kapsamlı bir literatür taraması

Corruption, a universal concept with deep historical roots, permeates societies and has varying implications on the economies. This study reviews the existing literature on corruption, with a particular focus on how corruption shapes income inequality, using an analogy of sand- versus grease-the-wheels hypotheses to explore the positive and negative aspects of corruption. Our aim is to contribute to the corruption literature by presenting theoretical and empirical insights in a clear and traceable manner. Previous studies on the relationship between corruption and income inequality have produced mixed results, which can be attributed to variations in data and methodologies. Some studies show positive associations between corruption and income inequality, while others show negative associations, echoing the controversy surrounding the sand- and grease-the-wheels hypotheses. However, there is also scant research suggesting a non-linear relationship between corruption and income inequality, characterized by an inverted U-shaped pattern. All of these diverse findings have important implications for policymakers, emphasizing the need for comprehensive reforms that address corruption and simultaneously tackle the immediate challenges faced by low-income individuals during the transitional period. In conclusion, this study systematically discusses the implications of these findings for policymakers and researchers, highlighting the relevance of this research for shaping effective policies and further investigations in this field.

Environmental Inequalities in Ecosystem Services Benefits of Green Infrastructure: A Case Study from China

Rapid urbanization is widespread globally, particularly impacting developing countries. In the face of climate challenges and shrinking public spaces resulting from urbanization, the significance of green infrastructure (GI) for human well-being and sustainability has increasingly taken center stage. This study employs an array of social-environmental benefits to evaluate GI’s contributions to human well-being, including mitigation of the urban heat island (UHI) effect, recreational functions, enhanced landscape connectivity, and efficient stormwater management. By mapping GI’s advantages, we scrutinized tradeoffs and ‘hot spots’ linked to these benefits within a metropolitan region. Moreover, we correlated GI’s advantages with the well-being of different socio-economic status (SES) groups by global and local regression. The study reveals environmental inequality, with higher SES areas—such as affluent and well-educated neighborhoods—providing superior and multifaceted GI benefits. The income coefficient is significantly positively correlated with the recreation function at the 1% significance level, while the coefficient for education is significant at the 10% level. Moreover, the income coefficient (0.349) surpasses the education coefficient (0.012). Our research also highlights that accessibility to GI’s recreational services may be an essential and overlooked indicator of environmental justice, especially for communities with a high proportion of elderly and low-income individuals.

Balancing Urban Development: Literature on the Nexus Between Affordable Housing and Urban Sprawl

The complex relationship between affordable housing and urban sprawl has major implications for cities all over the world. While urban sprawl offers lower housing costs and increased space as benefits, it also does present serious environmental, social, and economic issues. Undoubtedly, the rising cost of housing in the urban centers has forced the no income and the low-income populations to the periphery and thus increasing economic inequality and displacement. The growing urban sprawl has given rise to environmental degradation, social isolation, and economic inefficiency, which is further intensifying the displacement of low-income individuals and their families. This again is the remote cause of overcrowding as it restrains upward economic mobility. The aim of this research is to examine the complex relationship that exists between affordable housing and urban sprawl, and to propose ways to balance these dynamics. Key objectives include analyzing the adverse impacts of urban sprawl on the environment, societal fabric, and economic productivity; investigating the driving forces behind rising housing costs and their repercussions on low-income households; evaluating existing policies and strategies addressing affordable housing and urban sprawl; and proposing innovative solutions for sustainable urban development with equitable access to affordable housing. With the use of a literature review methodology, this study offers a comprehensive strategy. Stronger land use planning and zoning, improved public transportation and active transportation infrastructure, the expansion, building and preservation of more affordable housing, the promotion of social justice and community involvement and the use of technology and data-driven approaches are policy recommendations. The adoption of micro-units and tiny homes, co-housing and shared living arrangements, adaptive reuse and mixed-use development, community land trusts and housing cooperatives are some of the innovative recommendations. By striking a balance between affordable housing and sustainable urban development, these strategies hope to foster inclusive and thriving cities. Keywords: Urban sprawl, Affordable housing, Sustainable urban development, Low-Income Households, Land-Use Policy, Compact city planning, Community engagement

​​EXPLORING THE EFFECTIVENESS OF LAW CLINICS IN ENHANCING ACCESS TO JUSTICE FOR LOW-INCOME INDIVIDUALS IN MALAYSIA​

Law clinics are legal service providers that offer free or low-cost legal assistance to lowincome individuals, typically through the participation of law students who are supervised by legal professionals. This study aims to examine the effectiveness of law clinics in providing legal assistance to low-income individuals in Malaysia and improving their access to justice. Using a mixedmethods approach, the study first analyzed data on the utilization of law clinics in Malaysia, including the number of clients served, types of legal issues addressed, and success rates in resolving cases. The study also conducted in-depth interviews with law clinic staff, clients, and legal professionals to gather qualitative data on the challenges and successes of law clinics in assisting low-income individuals. The findings indicate that law clinics have been successful in providing legal assistance to a significant number of low-income individuals in Malaysia, but face challenges in terms of funding and capacity. Despite these challenges, law clinics have been able to make a positive impact on access to justice for low-income individuals through the provision of free legal services and the development of legal literacy among clients. The study concludes that law clinics have the potential to play a vital role in addressing the legal needs of low-income individuals in Malaysia and recommends measures to further enhance their effectiveness.

The association of the Affordable Care Act with nutrient consumption in adults in the United States.

The Patient Protection and Affordable Care Act, more commonly known as the ACA, was legislation passed in the United States in 2010 to expand access to health insurance coverage for millions of Americans with a key emphasis on preventive care. Nutrition plays a critical role in overall wellness, disease prevention and resilience to chronic illness but prior to the ACA many Americans did not have adequate health insurance coverage to ensure proper nutrition. With passage of the ACA, more individuals received access to nutritional counseling through their primary care physicians as well as prescription vitamins and supplements free of charge. The objective of this study was to evaluate the impact of a national health insurance reform on nutrient intake among general population, including more vulnerable low-income individuals and patients with chronic conditions. Using data from the National Health and Nutrition Examination Survey (NHANES), we identified 8,443 adults aged 21 years and older who participated in the survey before (2011-2012) and after the ACA (2015-2016) implementation and conducted a subgroup analysis of 952 respondents who identified as Medicaid beneficiaries and 719 patients with a history of cancer. Using pre-post study design and bivariate and multivariable logistic analyses, we compared nutrient intake from food and supplementation before and after the ACA and identified risk factors for inadequate intake. Our results suggest that intake of micronutrients found in nutrient-dense foods, mainly fruit and vegetables, has not changed significantly after the ACA. However, overall use of nutritional supplements increased after the ACA (p = 0.05), particularly magnesium (OR = 1.02), potassium (OR = 0.76), vitamin D (both D2, and D3, OR = 1.34), vitamin K (OR = 1.15) and zinc (OR = 0.83), for the general population as well as those in our subgroup analysis Cancer Survivors and Medicaid Recipients. Given the association of increased use of nutritional supplements and expansion of insurance access, particularly in our subgroup analysis, more research is necessary to understand the effect of increasing access to nutritional supplements on the overall intake of micro- and macronutrients to meet daily nutritional recommended allowances.

THE RELEVANCE OF SNAP PROGRAM ACCESSIBILITY FOR FOOD INSECURITY, FOCUSING ON ADULTS WITH DISABILITIES

Abstract Individuals with disabilities are not only more likely than their peers without disabilities to experience food insecurity, but also encounter disproportionate barriers to Supplemental Nutrition Assistance Program (SNAP) enrollment. This study examined associations between state-level measures of SNAP enrollment accessibility (flexibility, efficiency, and accessibility in the enrollment process; and the presence of either broad-based categorical eligibility or the Combined Application Project) with SNAP participation and food insecurity levels among low-income participants (income ≤185% of the poverty threshold) aged ≥15 years in the 2021 Current Population Survey, both overall (n=19,895) and among those with disabilities (n=3,484). In multi-level models adjusted for individual and state characteristics, living in a state with broad-based categorical eligibility was associated with higher rates of SNAP participation among all low-income individuals (b= 0.300, 95% CI: 0.096, 0.505). Among those with disabilities, having greater flexibility in SNAP enrollment (b= 0.141, 95% CI: 0.007, 0.276) and living in a state with the Combined Application Project (b= 0.271, 95% CI: 0.017, 0.525) were associated with a higher likelihood of SNAP participation. Living in a state with more efficient SNAP enrollment was associated with lower food insecurity levels (b= -0.073, 95% CI: -0.136, -0.010) among all low-income individuals and having broad-based categorical eligibility was associated with lower food insecurity levels (b= -0.237, 95% CI: -0.451, -0.022) among those with disabilities. These findings highlight the importance of SNAP program accessibility to address food insecurity among all low-income Americans and suggest that enrollment barriers may differ for people with and without disabilities.

THE SOCIAL STRATIFICATION OF INFORMAL CAREGIVING ARRANGEMENTS IN EUROPE

Abstract In ageing societies, the increasing quota of older and frail individuals creates unprecedented needs for care. As care is often costly and not adequately covered by the welfare state, care responsibilities for older individuals fall on the shoulders of family members. The study of informal care provision is acquiring centrality both in the social sciences and policy discourse, since the care load can bear negative consequences on a range of outcomes, from health (e.g., the “caregiver burden”) to employment. It is important to gain a better understanding of which individuals are the most likely to provide informal caregiving and face its consequences. In the present study, we explore the educational and income differences in the probability of providing informal caregiving to individuals living outside the household in Europe, using the Survey of Health, Aging and Retirement in Europe (SHARE, 2004-2020). As a contribution to the field, we aim at uncovering the mechanisms behind the socio-economic gradient in caregiving, such as differences in health and longevity and time constraints (due to employment and other care responsibilities) that are unequally distributed across social layers. Results show that individuals with tertiary education, and at the top of the income distribution, are more likely to provide care, net of several other factors. The study concludes with attempted explanations of the results, related to the fact that lower educated, and lower income individuals, can more often rely on publicly provided services and means-tested benefits.

Enhancing Socio-Economic Empowerment through Financial Inclusion Initiatives: A Case Study of Rwanda Union of the Blind

The research defines financial inclusion as the process of making sure vulnerable groups, like low-income individuals and the less privileged, have access to financial services and reasonable credit when they need it, at an affordable cost. This study focused on enhancing financial inclusion and socio-economic empowerment among individuals with disabilities in the Rwanda Union of the Blind. Using a descriptive and correlation research design, the researcher employed two primary data collection methods: questionnaires and interviews with structured questions for the respondents. The study involved 2400 members of the Rwanda Union of the Blind, with a sample size of 96 visually impaired individuals selected using the Yamane formula. Both quantitative and qualitative methods were used for data analysis, with Pearson’s correlation coefficient used to establish relationships between variables. The study's findings highlighted a 43% positive impact of financial inclusion on the socio-economic empowerment of people with visual impairment. Some respondents, particularly those who accessed loans from banks, acknowledged that financial services enabled them to excel in economic activities. Nevertheless, most respondents faced challenges due to discrimination and the absence of collateral, especially among disabled youth, hindering their access to finance. To achieve full financial inclusion, the study recommended that Microfinance Institutions or Banks should ensure equal opportunities and access to credit and financial services for individuals with disabilities. This can be achieved by providing information in formats accessible to them and making service points physically accessible. The government should promote awareness and involvement of visually impaired individuals in incomegenerating activities. Additionally, it was suggested that people with visual impairment should be encouraged to confidently apply for financial services. Keywords: Financial inclusion, Visual impairment, Socioeconomic empowerment, Financial services, People with disabilities.

The influence of pricing interventions in food choices on Brazil: An agent-based modelling approach

This study introduces an agent-based model (ABM) to analyse beef consumption trends in Brazil from 2017 to 2020. The ABM assesses the influence of price changes, specifically a rise in beef prices, on consumption behaviours and their diverse impacts across income groups. By integrating demographic and socioeconomic factors, the model replicates beef consumption decisions within Brazil. Findings show that consumer preferences are highly responsive to beef prices, with consumption decreasing as prices increase. A 60 % price increase due to a US$ 42/tCO2e tax could potentially reduce beef consumption by 55 %, cutting livestock-related greenhouse gas emissions by 53 % in Brazil. However, this tax would disproportionately affect lower-income individuals, worsening social inequality. To address potential food insecurity and ensure adequate nutrition for all, the consequences of food price interventions must be considered. Additional measures, such as tax incentives for plant-based alternatives, should be adopted to encourage suitable dietary choices. By thoughtfully assessing pricing intervention impacts, policymakers can support climate change mitigation, promote reduced meat consumption, and ensure fair access to nutritious food. This research improves our understanding of dietary decisions, the efficacy of pricing interventions, and their implications for affordability and social equality, with relevance beyond Brazil to nations facing similar challenges.

An intersectional analysis of long COVID prevalence

BackgroundLong COVID symptoms – which include brain fog, depression, and fatigue – are mild at best and debilitating at worst. Some U.S. health surveys have found that women, lower income individuals, and those with less education are overrepresented among adults with long COVID, but these studies do not address intersectionality. To fill this gap, we conduct an intersectional analysis of the prevalence and outcomes of long COVID in the U.S. We posit that disparities in long COVID have less to do with the virus itself and more to do with social determinants of health, especially those associated with occupational segregation and the gendered division of household work.MethodsWe use 10 rounds of Household Pulse Survey (HPS) data collected between June 2022 and March 2023 to perform an intersectional analysis using a battery of descriptive statistics that evaluate (1) the prevalence of long COVID and (2) the interference of long COVID symptoms with day-to-day activities. We also use the HPS data to estimate a set of multivariate logistic regressions that relate the odds of having long COVID and activity limitations due to long COVID to a set of individual characteristics as well as intersections by sex, race/ethnicity, education, and sexual orientation and gender identity.ResultsFindings indicate that women, some people of color, sexual and gender minorities, and people without college degrees are more likely to have long COVID and to have activity limitations from long COVID. Women have considerably higher odds of developing long COVID compared to men, a disparity exacerbated by having less education. Intersectional analysis by gender, race, ethnicity, and education reveals a striking step-like pattern: college-educated men have the lowest prevalence of long COVID while women without college educations have the highest prevalence. Daily activity limitations are more evenly distributed across demographics, but a different step-like pattern is present: fewer women with degrees have activity limitations while limitations are more widespread among men without degrees. Regression results confirm the negative association of long COVID with being a woman, less educated, Hispanic, and a sexual and gender minority, while results for the intersectional effects are more nuanced.ConclusionsResults point to systematic disparities in health, highlighting the urgent need for policies that increase access to quality healthcare, strengthen the social safety net, and reduce economic precarity.

Impact of income inequalities on subjective perception of older adult health: An analysis of healthy life expectancy in China from 1997 to 2006.

Driven by rapid socioeconomic development over recent decades, there are widening income inequalities and subjective health disparities among older adults in China. This study explored the relationship between income inequalities and self-rated healthy life expectancy (HLE) considering potential sex-specific differences. From a cohort of 1760 individuals aged ≥60 years from the China Health and Nutrition Survey (1997-2006), we calculated age-specific life expectancy (LE), HLE and the proportion of HLE to LE (HLE/LE) by sex using the IMaCh software, incorporated time-varying income levels of older adults. Although longevity has significantly improved, the well-being of Chinese older adults could be further enhanced by assessing HLE, as the results showed that at age 60 years, ~20% of their LE was characterized by unhealthiness. Discriminated by economic status, lower-income individuals experienced worse self-rated health compared with the general population and affluent counterparts. For instance, at age 60 years, the LE, HLE and HLE/LE of low-income men were 19.8 (95% CI 18.4-21.1), 16.2 years (95% CI 15.0-17.5) and 81.8%, respectively, lower than their general (21.7, 95% CI: 20.4-23.0; 18.0, 95% CI 16.8-19.2; and 82.9%) and high-income counterparts (25.1, 95% CI 23.1-27.2; 21.4, 95% CI 19.5-23.3; and 85.3%). Sex disparities were noticeable among low-income individuals in HLE/LE, with low-income women showing the most significant disadvantage. Income inequalities exacerbated subjective health disparities among older adults, particularly among lower-income individuals and women. Our findings carry significant implications for formulating public health and social welfare strategies, especially in nations grappling with an aging population and undergoing parallel socioeconomic development. Geriatr Gerontol Int 2024; 24: 109-115.

Does Abolishing a Copayment Increase Doctor Visits? A Comparative Case Study

Abstract Insurance coverage increases health care consumption, but less is known whether moderate copayments affect adults’ primary care utilization in a system characterized by gatekeeping. We analyze whether abolishing a 14-euro copayment for visits to general practitioners (GP) in Helsinki, the capital of Finland, increased the number of GP visits among adults and especially among low-income individuals. Using a difference-in-differences (DD) design and combining several administrative registers from 2011 to 2014, we find that the abolition is associated with only a small increase in GP visits (+0.04 visits annually, or +4.4 %, for all adults). The increase is driven by low-income adults (+0.06 visits, or +4.5 %, at the bottom 40 %). Although the point estimates are rather robustly positive, the conclusions regarding the statistical significance are sensitive to how we account for clustering in a setting characterized by only one treated cluster and a finite number of comparison clusters.

Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Race and ethnicity. Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Racial inequalities in mental healthcare use and mortality: a cross-sectional analysis of 1.2 million low-income individuals in Rio de Janeiro, Brazil 2010–2016

IntroductionMental health inequalities across racial and ethnic groups are large and unjust in many countries, yet these inequalities remain under-researched, particularly in low-income and middle-income countries such as Brazil. This...

Abstract C131: Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track?

Abstract Purpose: The COVID-19 pandemic disproportionately impacted racial/ethnic minority and low-income individuals and resulted in significant disruptions in preventive care for all groups. While severe declines in routine cancer screening were observed during pandemic shutdown periods, it is unclear whether return-to-screening rates following healthcare reopening are consistent across all groups. In this study we examine rates of breast cancer screening pre- and post- pandemic shutdown periods across race/ethnicity, age, and income among health plan enrollees in the United States (US) to inform screening catch-up strategies after COVID-19 disruptions. Methods: We conducted a retrospective analysis of breast cancer screening claims (including codes for mammography, breast MRI, digital breast tomography, and breast imaging) from Optum Clinformatics Data Mart among female enrollees from 2019-2021. Eligible enrollees included women, ages 40-75 with continuous enrollment 12 months prior to screening index month. Screening volume was calculated each calendar month during the three-year period, with January 2019-February 2020 as the pre-pandemic period, March 2020 through June 2020 as the pandemic closure period, and July 2020-December 2021 as the post-closure (reopening) pandemic period. We conducted an event study to calculate group-level monthly predicted probabilities of screening using a linear probability model with group interactions by month, controlling for demographic variables and comorbidities. Additionally, we used difference-in-difference (DD) regressions including group interacted with a post-closure pandemic dummy. The pandemic closure period months were excluded from our DD analysis. Results: Our study included 8,378,296 health plan enrolled women. Overall mammography screening decreased significantly during the pandemic closure phase (March-June 2020) but rebounded to higher levels in the post-closure period relative to baseline (3.76% to 3.96%). Screening rates were highest among non-Hispanic White women in the pre-pandemic period compared to other racial-ethnic groups. Our DD model suggests that White-Asian disparities increased in the post-pandemic period while other race/ethnic disparities remained constant. Additionally, disparities in screening by age changed during the pandemic. Although the oldest age group (65-75) had the highest screening rates in the pre-closure phase, they were slower to return to pre-pandemic levels of screening compared to younger age groups. Implications: Return to breast cancer screening among health plan enrollees in the US was robust. However, disparities in screening rates between groups in the pre-pandemic period were again observed in the reopening period, signaling lost opportunities to revamp structural inequities in care delivery following the pandemic. Further monitoring of return-to-screening disparities, particularly among more medically underserved groups, will be critical in informing interventions to address the long-term consequences resulting from the disruption of COVID-19 on cancer care. Citation Format: Jennifer Tsui, Sarah Axeen, John Thacker, Sonali Saluja, Laura Solano, Willow Pastard, Chun Nok Lam, Todd Schneberk, Cameron Kaplan. Disparities in breast cancer screening resumption among health plan enrollees in the US following the COVID-19 pandemic: Are all groups back on track? [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C131.

Abstract A016: Reducing the growing disparity of colorectal cancer screening among underserved populations in rural health clinics: The PRIME-CRC trial

Abstract Introduction: Colorectal cancer (CRC), the third leading cause of cancer death in the United States, can be significantly reduced if it is detected early. Although overall CRC screening rates have increased significantly, disparities persist among low-income individuals, adults with low literacy and those living in rural areas. These groups all have screening completion rates below 50%. Purpose of Study: To assess the effectiveness of a patient-centered, shared decision making, health literacy strategy to promote longer-term adherence to colorectal cancer (CRC) screening in resource-limited, rural health clinics via colonoscopy or annual fecal immunochemical test (FIT). Methods Used: A two-arm randomized control trial implemented in 6 rural community clinics. Clinics reported CRC baseline screening rates of 17% to 38%. Eligible patients, age 45-75, who were not up to date on CRC screening were recruited. Clinic based RAs screened and consented patients. They collected baseline data and then recommended screening and gave brief literacy and culturally appropriate education using a pamphlet developed by the authors (4th grade level). The RA used shared decision-making techniques to aid patients in selecting the test they prefer and that met their needs – colonoscopy or FIT. All patients who selected the FIT kit were given simplified instructions (3rd grade level) and a demonstration of how to use it and those who chose colonoscopy were given simplified colonoscopy prep instructions and had a referral made to GI clinic. Patients were randomized into intervention (INT) arm or enhanced usual care (EUC) arm. Those in INT who selected the FIT (and had not returned it) at 4, 8 and 12 weeks received an automated follow-up call or text from a provider at their clinic using plain language and motivational messages encouraging patients to complete the FIT (colonoscopy INT patients received reminder calls prior to appointment to remind them about prepping for procedure and their appointment). Summary of Results: 734 patients have been enrolled to date: 361 in INT arm and 373 in EUC arm; 64.1% are African American, 60.3% women; 38% have limited literacy; 71.8% highest level of education completed was high school or less; only 5.6% have annual incomes > $50,000. 72.4% of patients had heard of tests to screen for CRC and 75.4% had a doctor or nurse recommend screening for CRC in the past. With regard to screening tests, 5.6% of patients have chosen a colonoscopy and 94.4% have selected a FIT. Screening to date in Year 1: 56.0% completed screening by FIT in INT arm versus 54.2% in EUC arm; only 20% have completed screening by colonoscopy to date. Conclusions: Simplified instructions accompanied by a face-to-face demonstration of FIT, use of “teach back” to confirm understanding with a follow-up automated text message or call if needed, facilitated completion rates of all patients, particularly those with limited literacy. This has not been effective to date with colonoscopy. Citation Format: Connie L. Arnold, Joseph Dean, James Morris, Elise Reed, Laura Curtis, Terry Davis. Reducing the growing disparity of colorectal cancer screening among underserved populations in rural health clinics: The PRIME-CRC trial [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A016.