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India’s cities face key challenges to improving public health outcomes. First, unequally distributed public resources create insanitary conditions, especially in slums – threatening everyone’s health, as suggested by poor child growth even amongst the wealthiest. Second, devolving services to elected bodies works poorly for highly technical services like public health. Third, services are highly fragmented. This paper examines the differences in the organisation and management of municipal services in Chennai and Delhi, two cities with sharply contrasting health indicators. Chennai mitigates these challenges by retaining professional management of service delivery and actively serving vulnerable populations − while services in Delhi are quite constrained. Management and institutional issues have received inadequate attention in the public health literature on developing countries, and the policy lessons from Chennai have wide relevance.

Importance: Nearly 34 million adults – 17 percent of all American adults – have co-occurring mental and physical health conditions. However, the extent to which increased health insurance coverage has facilitated access to needed health care services among this population remains unclear. Objective: Prior research suggests that people with serious psychological distress (SPD) and cancer, heart disease, diabetes, asthma, or hypertension report worse access to care than people with the same physical conditions but no SPD. While the recent expansion in health insurance coverage was expected to improve access to care for people with SPD, access barriers that people with SPD report remain underexplored. Setting: Using the cross-sectional data from the National Health Interview Survey 2011-2015, we examined self-reported health care access barriers among adults (between ages 18 to 64) with SPD and co-occurring physical health conditions. Results: Our sample included 45,294 individuals with chronic conditions (heart disease, high blood pressure, diabetes, cancer, or asthma). Among them, 3,639 also had SPD. After controlling for demographic and socioeconomic factors, results of multivariate logistic regressions showed that individuals with co-occurring SPD and a physical health condition were significantly more likely to report that they had worse health insurance coverage compared to the prior year (OR=1.32, p<0.01), that doctor's office informed that they were not accepting new patients (OR=2.09, p<0.001), that the doctor's office stated they did not accept the particular health insurance they have (OR=1.98, p<0.001), that they couldn't get an appointment soon enough (OR=2.42, p<0.001), they had no transportation to get to the doctor (OR=3.23, p<0.001), and that overall they had trouble finding a doctor/provider (OR=2.12, p<0.001). Conclusions: Our results suggest that despite an increase in health insurance coverage between 2011 and 2015, barriers to access remain a significant concern for individuals with co-occurring SPD and physical health conditions.

Background Few studies have investigated the consequences of caregiving on the objectively measured physiological health outcomes in China. This study used population-based longitudinal data to examine the association between parental caregiving and blood pressure among Chinese women. Method This is a retrospective analysis of 2586 women using five waves of data from the Ever-Married Women Survey component of the China Health and Nutrition Survey (2000, 2004, 2006, 2009, and 2011). We applied growth curve models to examine trajectories of systolic blood pressure (SBP) and diastolic blood pressure (DBP) associated with parental caregiving among women in China. Results In multivariable analyses of blood pressure trajectories adjusting for potential confounders, parental caregivers had higher systolic (β-coefficient (β) = 1.16; p ≤ 0.01) and diastolic blood pressure (β = 0.75; p ≤ 0.01) compared with non-caregivers across multiple waves. Caregivers and non-caregivers had similar levels of systolic blood pressure at baseline, but caregivers exhibited relatively higher growth rate over time. Diastolic blood pressure was much higher among caregivers at the baseline measure, and across time relative to non-caregivers. Moreover, low-intensity but not high-intensity caregivers showed higher growth rate compared with non-caregivers for both SBP and DBP. Discussion Our results demonstrate the negative cardiovascular consequences of parental caregiving among Chinese women. Findings from the study can be used to develop future stress management interventions to decrease hypertension risk within women who provide care to their parents.

Thurka Sangaramoorthy, Assistant Professor, Department of Anthropology, University of Maryland

Objectives:  We examined changes in  health care access  and utilization associated with the Patient Protection and  Affordable Care Act  (ACA) for different Asian American subgroups relative to non-Latino whites (whites). Research Design:  Using 2003–2017 California Health Interview Survey data, we examined changes in 4  health care access  measures and 2 utilization measures among whites and 7 Asian American subgroups. We estimated the unadjusted and adjusted percentage point changes on the absolute scale from the pre-ACA to post-ACA periods. Adjusted estimates were obtained from multivariable logistic regression models that controlled for predisposing, enabling, and need factors. We also estimated the pre-ACA to post-ACA changes between whites and Asian American subgroups using a difference-in-difference approach. Results:  After the ACA was implemented, uninsurance decreased among all Asian American subgroups, but improvements in disparities relative to whites in these measures were limited. In particular, Koreans had the largest absolute reduction in uninsurance (−16.8 percentage points) and were the only subgroup with a significant reduction in terms of disparities relative to whites (−10.1 percentage points). However, little or no improvement was observed in the other 3 access measures (having a usual source of care, delayed medical care in past year, or delayed prescription drug use in past year) and 2 utilization measures (having a physician visit or emergency department visit in past year). Conclusions:  Despite coverage gains among Asian American subgroups, especially Koreans, disparities in access and utilization persisted across all Asian American subgroups.

LGBTQ youth are at greater risk for compromised health, yet large-scale health promotion programs for LGBTQ young people have been slow to develop. LGBTQ community-based organizations—which provide LGBTQ-focused support and services—have existed for decades, but have not been a focus of the LGBTQ youth health literature. The current study used a contemporary sample of LGBTQ youth (age 15–21;  M  = 18.81;  n  = 1045) to examine who participates in LGBTQ community-based organizations, and the association between participation and self-reported mental health and substance use. Youth who participated in LGBTQ community-based organizations were more likely to be assigned male at birth, transgender, youth of color, and accessing free-or-reduced lunch. Participation was associated with concurrent and longitudinal reports of mental health and substance use. LGBTQ community-based organizations may be an underutilized resource for promoting LGBTQ youth health.

Sexual and gender minority (SGM) youth are more likely to use alcohol than their heterosexual cisgender peers. At the same time, SGM youth experience sexuality- and gender identity-specific stressors known to exacerbate negative health outcomes. Though scholars have established a link between minority stressors (e.g., internalized stigma and victimization) and increased alcohol use for SGM youth as a whole, there is little indication of whether internalized stigma and victimization are more strongly associated with alcohol use for specific groups of SGM youth. A United States sample of 11,811 racially and geographically diverse 13–17 year old SGM youth was used to employ a series of gender-stratified multivariable regression models to examine the association among internalized stigma, victimization, and alcohol-related behaviors, and whether they differed for specific groups of sexual minority youth. Sexual orientation moderated several associations between sexual minority stressors (i.e., victimization and stigma) and youth’s alcohol use (i.e., recent use and heavy episodic drinking) across models stratified by gender (i.e., male, female, and non-binary). For example, bisexual boys had stronger associations between SGM-specific victimization and alcohol use frequency and heavy episodic drinking relative to gay boys; conversely, victimization and alcohol use frequency were more weakly associated among bisexual girls relative to lesbian/gay girls. Pansexual girls showed weaker associations between internalized stigma and alcohol use frequency compared to lesbian/gay girls. This paper demonstrates who among SGM youth are more likely to engage in alcohol-related behaviors as a function of differential forms of SGM-related victimization and stigma. These findings can inform substance use interventions that are tailored to youth of diverse sexual orientations and gender identities.

Bootstraps of Oppression: A Theoretical Framework of Structural Inequality in Policy Decision Making

Alternative Trajectories in Body Weight, Mental and Cognitive Health among Older Americans: Roles of Genetics and Earlier SES

Complex interrelationships between race, sex, obesity and depression have been well-documented. Because of differences in associations between socioeconomic status (SES) and health by race, determining the role of SES may help to further explicate these relationships. The aim of this study was to determine how race and income interact with obesity on depression. Combining data from the 2007-2014 National Health and Nutrition Examination Survey, depressive symptoms was measured with the Patient Health Questionnaire-9 and obesity was assessed as body mass index ≥30 kg/m 2 . Three-way interactions between race, income and obesity on depressive symptoms were determined using ordered regression models. Significant interactions between race, middle income and obesity (OR = 0.66, 95% CI = 0.22-1.96) suggested that, among white women, obesity is positively associated with depressive symptoms across income levels, while obesity was not associated with depression for African American women at any income level. Obesity was only associated with depressive symptoms among middle-income white men (OR = 1.44, 95% CI = 1.02-2.03) and among high-income African American men (OR = 4.65, 95% CI = 1.48-14.59). The associations between obesity and depressive symptoms vary greatly by race and income. Findings from this study underscore the importance of addressing obesity and depression among higher income African American men.