Mothers who work away from home tend to stop breastfeeding earlier than their nonworking counterparts due to workplace barriers. Barriers to breastfeeding discriminate against women and may lead to inequities in children's health outcomes. Guaranteeing paid breastfeeding breaks at work is 1 mechanism that can improve mothers' opportunity to breastfeed in the workplace.
Robust evidence from low- and middle-income countries (LMICs) suggests that maternal education is associated with better child health outcomes. However, whether or not policies aimed at increasing access to education, including tuition-free education policies, contribute to lower infant and neonatal mortality has not been empirically tested. We joined country-level data on national education policies for 37 LMICs to information on live births to young mothers aged 15-21 years, who were surveyed as part of the population-based Demographic and Health Surveys. We used propensity scores to match births to mothers who were exposed to a tuition-free primary education policy with births to mothers who were not, based on individual-level, household, and country-level characteristics, including GDP per capita, urbanization, and health expenditures per capita. Multilevel logistic regression models, fitted using generalized estimating equations, were used to estimate the effect of exposure to tuition-free primary education policies on the risk of infant and neonatal mortality. We also tested whether this effect was modified by household socioeconomic status. The propensity score matched samples for analyses of infant and neonatal mortality comprised 24,396 and 36,030 births, respectively, from 23 countries. Multilevel regression analyses showed that, on average, exposure to a tuition-free education policy was associated with 15 (95% CI = -32, 1) fewer infant and 5 (95% CI = -13, 4) fewer neonatal deaths per 1000 live births. We found no strong evidence of heterogeneity of this effect by socioeconomic level.
Growing work demonstrates social gradients in infant mortality within countries. However, few studies have compared the magnitude of these inequalities cross-nationally. Even fewer have assessed the determinants of social inequalities in infant mortality across countries. This study provides a comprehensive and comparative analysis of social inequalities in infant mortality in 53 low-and-middle-income countries (LMICs). We used the most recent nationally representative household samples (n = 874,207) collected through the Demographic Health Surveys (DHS) to calculate rates of infant mortality. The relative and absolute concentration indices were used to quantify social inequalities in infant mortality. Additionally, we used meta-regression analyses to examine whether levels of inequality in proximate determinants of infant mortality were associated with social inequalities in infant mortality across countries. Estimates of both the relative and the absolute concentration indices showed a substantial variation in social inequalities in infant mortality among LMICs. Meta-regression analyses showed that, across countries, the relative concentration of teenage pregnancy among poorer households was positively associated with the relative concentration of infant mortality among these groups (beta = 0.333, 95% CI = 0.115 0.551). Our results demonstrate that the concentration of infant deaths among socioeconomically disadvantaged households in the majority of LMICs remains an important health and social policy concern. The findings suggest that policies designed to reduce the concentration of teenage pregnancy among mothers in lower socioeconomic groups may mitigate social inequalities in infant mortality.
Extant studies universally document a positive gradient between socioeconomic status (SES) and health. A notable exception is the apparent concentration of HIV/AIDS among wealthier individuals. This paper uses data from the Demographic Health Surveys and AIDS Indicator Surveys to examine socioeconomic inequalities in HIV/AIDS prevalence in 24 sub-Saharan African (SSA) countries, the region that accounts for two-thirds of the global HIV/AIDS burden.
Low-income urban working mothers face many challenges in their domestic, environmental, and working conditions that may affect their mental health. In India, a high prevalence of mental health disorders has been recorded in young women, but there has been little research to examine the factors that affect their mental health at home and work.
The economic burden of diabetes and the effects of the disease on the labor force are of substantial importance to policy makers. We examined the impact of diabetes on leaving the labor force across sixteen countries, using data about 66,542 participants in the Survey of Health, Ageing and Retirement in Europe; the US Health and Retirement Survey; or the English Longitudinal Study of Ageing. After matching people with diabetes to those without the disease in terms of age, sex, and years of education, we used Cox proportional hazards analyses to estimate the effect of diabetes on time of leaving the labor force. Across the sixteen countries, people diagnosed with diabetes had a 30 percent increase in the rate of labor-force exit, compared to people without the disease. The costs associated with earlier labor-force exit are likely to be substantial. These findings further support the value of greater public- and private-sector investment in preventing and managing diabetes.
Objectives. We examined the efficiency of country-specific health care spending in improving life expectancies for men and women. Methods. We estimated efficiencies of health care spending for 27 Organisation for Economic Co-operation and Development (OECD) countries during the period 1991 to 2007 using multivariable regression models, including country fixed-effects and controlling for time-varying levels of national social expenditures, economic development, and health behaviors. Results. Findings indicated robust differences in health-spending efficiency. A 1% annual increase in health expenditures was associated with percent changes in life expectancy ranging from 0.020 in the United States (95% confidence interval [CI]?=?0.008, 0.032) to 0.121 in Germany (95% CI?=?0.099, 0.143). Health-spending increases were associated with greater life expectancy improvements for men than for women in nearly every OECD country. Conclusions. This is the first study to our knowledge to estimate the effect of country-specific health expenditures on life expectancies of men and women. Future work understanding the determinants of these differences has the potential to improve the overall efficiency and equity of national health systems. (Am J Public Health. Published online ahead of print December 12, 2013: e1-e7. doi:10.2105/AJPH.2013.301494).
Objectives. We examined associations between macrolevel economic factors hypothesized to drive changes in distributions of weight and body mass index (BMI) in a representative sample of 200796 men and women from 40 low- and middle-income countries. Methods. We used meta-regressions to describe ecological associations between macrolevel factors and mean BMIs across countries. Multilevel regression was used to assess the relation between macrolevel economic characteristics and individual odds of underweight and overweight relative to normal weight. Results. In multilevel analyses adjusting for individual-level characteristics, a 1-standard-deviation increase in trade liberalization was associated with 13% (95% confidence interval [CI]?=?0.76, 0.99), 17% (95% CI?=?0.71, 0.96), 13% (95% CI?=?0.76, 1.00), and 14% (95% CI?=?0.75, 0.99) lower odds of underweight relative to normal weight among rural men, rural women, urban men, and urban women, respectively. Economic development was consistently associated with higher odds of overweight relative to normal weight. Among rural men, a 1-standard-deviation increase in foreign direct investment was associated with 17% (95% CI?=?1.02, 1.35) higher odds of overweight relative to normal weight. Conclusions. Macrolevel economic factors may be implicated in global shifts in epidemiological patterns of weight. (Am J Public Health. Published online ahead of print November 14, 2013: e1-e10. doi:10.2105/AJPH.2013.301392).
United Nations (UN) member states have universally recognised the right to health in international agreements, but protection of this right at the national level remains incomplete. This article examines the level and scope of constitutional protection of specific rights to public health and medical care, as well as the broad right to health. We analysed health rights in the constitutions of 191 UN countries in 2007 and 2011. We examined how rights protections varied across the year of constitutional adoption; national income group and region; and for vulnerable groups within each country. A minority of the countries guaranteed the rights to public health (14%), medical care (38%) and overall health (36%) in their constitutions in 2011. Free medical care was constitutionally protected in 9% of the countries. Thirteen per cent of the constitutions guaranteed childrens right to health or medical care, 6% did so for persons with disabilities and 5% for each of the elderly and the socio-economically disadvantaged. Valuable next steps include regular monitoring of the national protection of health rights recognised in international agreements, analyses of the impact of health rights on health outcomes and longitudinal multi-level studies to assess whether specific formulations of the rights have greater impact.
Globalization has transformed the workplace at the same time that increasing numbers of children live in families in which all adults work for pay outside the home. Extensive research evidence demonstrates the importance of parental involvement in the early years of a childs life. Yet, parents caring for young children may face challenges in fulfilling both work and family responsibilities under current labor force conditions. In this article, we review the evidence on the importance of parental care for meeting young childrens routine care needs, preventive health care needs, and curative medical treatment requirements. We examine the evidence regarding the impact of four policies in particular on young childrens health and development: parental leave, breastfeeding breaks, early childhood care and education, and leave for childrens health needs. Last, we examine the availability of these policies worldwide and discuss the potential economic implications.
The United States does not guarantee families a wide range of supportive workplace policies such as paid maternity and paternity leave or paid leave to care for sick children. Proposals to provide such benefits are invariably met with the complaint that the costs would reduce employment and undermine the international competitiveness of American businesses. In this article, Alison Earle, Zitha Mokomane, and Jody Heymann explore whether paid leave and other work-family policies that support childrens development exist in countries that are economically competitive and have low unemployment rates. Their data show that the answer is yes. Using indicators of competitiveness gathered by the World Economic Forum, the authors identify fifteen countries, including the United States, that have been among the top twenty countries in competitiveness rankings for at least eight of ten years. To this group they add China and India, both rising competitors in the global economy. They find that every one of these countries, except the United States, guarantees some form of paid leave for new mothers as well as annual leave. And all but Switzerland and the United States guarantee paid leave for new fathers. The authors perform a similar exercise to identify thirteen advanced countries with consistently low unemployment rates, again including the United States. The majority of these countries provide paid leave for new mothers, paid leave for new fathers, paid leave to care for childrens health care needs, breast-feeding breaks, paid vacation leave, and a weekly day of rest. Of these, the United States guarantees only breast-feeding breaks (part of the recently passed health care legislation). The authors global examination of the most competitive economies as well as the economies with low unemployment rates makes clear that ensuring that all parents are available to care for their childrens healthy development does not preclude a country from being highly competitive economically.
Childhood vaccination is a proven and cost-effective way to reduce childhood mortality; however, participation in vaccination programs is not universal even where programs are free or low cost. Studies in diverse countries have reported work conflicts as limiting parents ability to vaccinate their children. Using policy data for 185 UN member countries, we explore the hypothesis that an increased opportunity for parents to bring children to vaccination sites will translate into higher childhood vaccination rates. To do so, we use OLS regression to examine the relationship between the duration of adequately paid maternal leave and the uptake of vaccines. We find that a higher number of full-time equivalent weeks of paid maternal leave is associated with higher childhood vaccination rates, even after controlling for GDP per capita, health care expenditures, and social factors. Further research is needed to assess whether this association is upheld in longitudinal and intervention studies, as well as whether other forms of leave such as paid leave to care for the health of family members is effective at increasing the ability of parents to bring children for needed preventive care.
Operating at a societal level, public policy is often one of our best approaches to addressing social determinants of health (SDH). Yet, limited data availability has constrained past research on how national social policy choices affect health outcomes. We developed a new data infrastructure to illustrate how globally comparative data on labor policy might be used to examine the impact of social policy on health.
Over half of American workers are holding a paid job while also providing unpaid assistance and support to a family member. Research shows that family members who provide care to children or adults with special health care needs are themselves at risk of physical and mental health problems. Yet, little research has explored how the work environment mediates the effects of caregiving on caregivers mental and physical health. With a sample of 2455 currently employed U.S. adults from the Work, Family, Community Nexus (WFCN) survey, a random-digit dial, nationally representative survey of Americans aged 18-69, we examine whether paid leave and flexibility policies mediate the relationship between caregiving and health. In Ordinary Least Squares regression models, we find that paid leave to address family members health was associated with better mental health status as measured by the 5-item Mental Health Inventory and paid sick leave with better physical health status as measured by self-rated overall health status. A supportive supervisor was also associated with improvements in mental and physical health. For both men and women, paid leave and a supervisors support offset some or all of the negative effects of caregiving, but for women, the buffering effects of working conditions are slightly larger. Enhancing the unpaid leave guaranteed in the U.S. Family and Medical Leave Act so that it is paid and passing national paid sick days legislation will help ensure that employed caregivers can retain their jobs, receive needed income, and meet their own mental and physical health needs.
Multiple drug-resistance in new tuberculosis (TB) cases accounts for the majority of all multiple drug-resistant TB (MDR-TB) worldwide. Effective control requires determining which new TB patients should be tested for MDR disease, yet the effectiveness of global screening recommendations of high-risk groups is unknown.
Two thirds of Canadian adults participate in the workforce. Their health and that of their families can be markedly affected by the availability of paid sick leave, paid leave to care for family members health and paid parental leave.
Simulation models are useful in policy planning for tuberculosis (TB) control. To accurately assess interventions, important modifiers of the epidemic should be accounted for in evaluative models. Improvements in population health were associated with the declining TB epidemic in the pre-antibiotic era and may be relevant today. The objective of this study was to develop and validate a TB transmission model that accounted for changes in population health.
As a result of the HIV/AIDS pandemic, there are now more than 12 million orphans in sub-Saharan Africa. The majority of these children have been absorbed into their extended families. A minority of AIDS orphans and other vulnerable children are living in residential care facilities. Although concerns have been raised regarding the care received in such facilities, very little is known about childrens perspectives on their own experiences residing in these institutions. As part of an ongoing initiative to better understand the impact of HIV/AIDS in Southern Africa and what can be done to address needs, one-on-one interviews were conducted with the children and youth residents, and graduates of a residential care facility in Botswana. The children report on the importance of having uninterrupted access to food, shelter and schooling and a sense of belonging. However, they also reveal a profound ambivalence towards their paid caregivers, and the other children residents. They describe being separated from siblings, missing their families and feeling disconnected from the community at large. Their narratives offer insight into ways in which we can better meet their complex needs. Policy implications are discussed.
Pediatric HIV infections jeopardize childrens health and survival. Much less is known about how the experiences of being orphaned, living with chronically ill parents, or living in a severely affected community impact child health. Our study responds by examining which HIV/AIDS-related experiences place children at greatest risk for poor health. Data from the 2004-2005 Malawi Integrated Household Survey were analyzed using logistic multilevel modeling to examine whether HIV/AIDS-related experiences within the family and community predicted reported health status among children age 6-17 years. We found higher burdens of acute and chronic morbidity for children whose parents have an AIDS-related illness. No other AIDS-related exposure, including orphanhood and recent household deaths, demonstrated a clear relationship with health status. Children living with sick parents may be at increased risk due to the spread of infectious disease and receiving limited adult care. Community home-based care programs are best situated to identify children in these difficult circumstances and to mitigate their disadvantage.
National paid sick day and paid sick leave policies are compared in 22 countries ranked highly in terms of economic and human development. The authors calculate the financial support available to workers facing two different kinds of health problems: a case of the flu that requires missing 5 days of work, and a cancer treatment that requires 50 days of absence. Only 3 countries--the United States, Canada, and Japan--have no national policy requiring employers to provide paid sick days for workers who need to miss 5 days of work to recover from the flu. Eleven countries guarantee workers earning the national median wage full pay for all 5 days. In Ireland and the United Kingdom, the full-time equivalent benefits are more generous for low-wage workers than for workers earning the national median. The United States is the only country that does not provide paid sick leave for a worker undergoing a 50-day cancer treatment. Luxembourg and Norway provide 50 full-time equivalent working days of leave, while New Zealand provides the least, at 5 days. In 6 countries, paid sick leave benefits are more generous for low-wage workers than for median-wage workers.
Ensuring working mothers ability to breast-feed is crucial given that breast-feeding substantially reduces infant morbidity and mortality while promoting maternal health. Working conditions, rules on the job, supervisors and co-workers can all raise or lower barriers to breast-feeding. Around the world, 127 countries guarantee working women the right to breast-feed. Canada does not provide this assurance, despite the fact that the majority of infants are born to women in the labour force. This has profound implications for the health of infants and mothers alike. Solutions exist: extending current policies to ensure adequate maternity leave is available for all Canadians, legislating a right to breast-feed while working, and adapting workplaces to make this practical.
There are an estimated 15 million AIDS orphans worldwide. Families play an important role in safeguarding orphans, but they may be increasingly compromised by the HIV/AIDS epidemic. The international aid community has recognized the need to help families continue caring for orphaned children by strengthening their safety nets. Before we build new structures, however, we need to know the extent to which community and public safety nets already provide support to families with orphans. To address this gap, we analyzed nationally representative data from 27,495 children in the 2004-2005 Malawi Integrated Household Survey. We found that communities commonly assisted orphan households through private transfers; organized responses to the orphan crisis were far less frequent. Friends and relatives provided assistance to over 75% of orphan households through private gifts, but the value of such support was relatively low. Over 40% of orphans lived in a community with support groups for the chronically ill and approximately a third of these communities provided services specifically for orphans and other vulnerable children. Public programs, which form a final safety net for vulnerable households, were more widespread. Free/subsidized agricultural inputs and food were the most commonly used public safety nets by childrens households in the past year (44 and 13%, respectively), and households with orphans were more likely to be beneficiaries. Malawi is poised to drastically expand safety nets to orphans and their families, and these findings provide an important foundation for this process.
This paper examines different child care arrangements utilized by working families in countries undergoing major socio-economic transitions, with a focus on modeling parental decisions to leave children home alone.
Families play central roles in the HIV/AIDS pandemic, caring for both orphaned children and the ill. This extra caregiving depletes two family resources essential for supporting children: time and money. We use recent data from published studies in sub-Saharan Africa to illustrate deficits and document community responses. In Botswana, parents caring for the chronically ill had less time for their preschool children (74 versus 96 hours per month) and were almost twice as likely to leave children home alone (53% versus 27%); these children experienced greater health and academic problems. Caregiving often prevented adults from working full time or earning their previous level of income; 47% of orphan caregivers and 64% of HIV/AIDS caregivers reported financial difficulties due to caregiving. Communities can play an important role in helping families provide adequate childcare and financial support. Unfortunately, while communities commonly offer informal assistance, the value of such support is not adequate to match the magnitude of need: 75% of childrens families in Malawi received assistance from their social network, but averaging only US$81 annually. We suggest communities can strengthen the capacity of families by implementing affordable quality childcare for 0-6 year olds, after-school programming for older children and youth, supportive care for ill children and parents, microlending to enhance earnings, training to increase access to quality jobs, decent working conditions, social insurance for the informal sector, and income and food transfers when families are unable to make ends meet.
Climate change is among the major challenges for health this century, and adaptation to manage adverse health outcomes will be unavoidable. The risks in Ontario - Canadas most populous province - include increasing temperatures, more frequent and intense extreme weather events, and alterations to precipitation regimes. Socio-economic-demographic patterns could magnify the implications climate change has for Ontario, including the presence of rapidly growing vulnerable populations, exacerbation of warming trends by heat-islands in large urban areas, and connectedness to global transportation networks. This study examines climate change adaptation in the public health sector in Ontario using information from interviews with government officials.
The emergence of drug-resistant tuberculosis has brought with it diverse perspectives concerning the way in which the disease should be managed. The media is an important source of these perspectives, as they perform the dual role of reflecting and shaping public discourse. In this study, we are interested in how the media presents multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in South Africa, where both variants are a growing public health concern. We examined newspaper content from 310 South African newspaper articles from February 2004 to July 2009 that discussed MDR-TB and XDR-TB. Newspaper articles were collected from the Dow Jones Factiva database and imported into QDA Miner v3.2.1 for analysis. Using Attride-Stirlings thematic network analysis method, articles were analyzed according to themes, sub-themes, and thematic networks. This analysis identified two main dimensions: causes of MDR/XDR-TB and treatment approaches/solutions. Causes of MDR/XDR-TB revolved around three main global themes: i) patient-centred causes (32.6%); ii) lack of infection control procedures (18.7%); and iii) health systems failures (19.4%). Treatment approaches or solutions to tackling MDR/XDR-TB focused on i) patient targeted solutions (38.4%); ii) improving infection control (12.3%); iii) systems restructuring (10.6%); and iv) new diagnostic and therapeutic options (10%). Our analysis identifies a trend in the South African media to identify a broad range of causes of MDR/XDR-TB, while emphasizing that treatment approaches should be directed primarily at the individual. Of particular importance is the fact that such a perspective runs contrary to the World Health Organizations (WHO) recommendations for approaching the TB epidemic, in particular by insufficiently addressing systemic and social drivers of the epidemic. Due to the medias potential influence on policy formation, how the media presents issues - especially issues pertaining to emerging public health concerns - should warrant more attention.
In India, the low rate of employment of people with disabilities is a large problem in the growing economy. Looking at one advocacy groups strategies for influencing the private sector and lobbying the Indian government for more responsive employment policies, this article focuses on NCPEDPs holistic approach to increasing employment of people with disabilities as an example of notable, innovative practice. The article examines NCPEDPs strategies towards the private sector, public policy, and civil society, including its Disability Awards (highlighting inclusive workplaces), the 2001 and 2011 Census campaigns efforts for people with disabilities to become accurately counted, and its networks of disability organizations that disseminate relevant information and campaign for greater equality across the nation. The benefits and limitations of these strategies are then assessed for lessons regarding the strategies available to small nongovernmental organizations seeking to influence employment, the private sector and public policy in other settings.
Despite significant gains in legal rights for people with disabilities, the employment rate for individuals with disabilities in many countries remains extremely low. Programs to promote the inclusion of people with disabilities in the workforce can have an important impact on individuals economic and social prospects, as well as societal benefits.
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