Three Papers on Impacts of Regulatory Policies on Well-being of Vulnerable Populations

This dissertation investigated the impacts of regulatory policies on well-being of immigrant families and low-income families, which offers evidence for policymakers to evaluate the necessity of employing harsh measures. In the first paper, I used the nationally representative National Health Interview Survey (2000-2012) to study the health and mental health impacts of local immigration enforcement policies, under Section 287(g) of the Illegal Immigration Reform and Immigrant Responsibility Act and the Secure Communities Program. I found some evidence of local immigration enforcement policies negatively impacting the mental health and self-rated health of Latino immigrants. In the second paper, I explored relationships between participation in the Temporary Assistance for Needy Families (TANF) program and parental investments in children, and how stringencies in state TANF policy requirements impacted the relationships. I used the 2004 and 2008 panels of Survey on Income and Program Participation (SIPP) and found that TANF participation was associated with increased family meal times and decreased incidences of family outings and reading time. TANF participation was not associated with other areas of parenting (e.g., extracurricular activity participation, family rules on watching TV, positive parenting, parenting stress, and parental expectation). Also, stringent state TANF policy characteristics were not associated with negative parenting behaviors. In the last paper, I investigated how the stringencies of state TANF policy were associated with single mothers’ long-term trajectories of welfare use, labor supply, and earned income. I used the 1996, 2001, and 2004 panels of SIPP data (1996-2007), covering the decade following TANF implementation. Findings indicated that stringent state TANF policies were strongly related to single mothers’ lower likelihood to participate in TANF; however, single mothers used other welfare programs (e.g., SNAP and SSI) to the same extent as single mothers living in states with less stringent TANF policies. Also, stringent policies did not lead to higher levels of labor supply or earned income

Utilizing Consumer-Directed Care Among Older Adults: Identifying Barriers From Behavioral Economics Perspectives

Consumer-directed Care (CDC) empowers older people to flexibly arrange services and enhances their well-being. Prior studies have suggested that limited attention and hassle costs are major demand-side barriers to using CDC. However, many other psychosocial factors were unexplored. In this study, we explore associations between CDC utilization and a wider range of psychosocial factors based on behavioral economics theories. A cross-sectional telephone survey of older persons (or family members that represent them) was conducted in Guangzhou, China in 2021. We adopted a two-stage sampling method based on administrative records and analyzed the data using multivariate logistic models. Procedural literacy, hassle costs, and social norms regarding CDC were associated with using CDC. The findings reveal nuances in the decision-making process, and people are not unboundedly rational in making care-related decisions. Policymakers could employ cost-effective tools to facilitate CDC utilization and optimize resources to address the most crucial service barriers

Developing an Operationalized Framework for Comparing Consumer-Directed Care for Older Adults: Evidence from Expert Survey and Cross-National Comparison

Consumer-directed care (CDC) programs for older people aim to optimize health outcomes by offering clients control and flexibility regarding service arrangements. However, policy design features may differ due to heterogenous sociostructural systems. By operationalizing a framework with three dimensions of CDC, i.e. control and direct services, variety of service options, and information and support, we analyzed how countries vary in their policy designs to achieve consumer direction. Using an expert survey (n = 20) and cross-national document analysis, we analyzed 12 CDC programs from seven selected countries: the United States, the United Kingdom, Germany, the Netherlands, China, Australia, and Spain. Among the three dimensions, CDC programs placed more emphasis on and displayed more homogenous performance of policy designs that achieve consumer direction in the dimension of control and direct services, while less emphasis was placed on and more heterogenous performance displayed in the dimensions of variety of service options and information and support. We offer a systematically operationalized framework to investigate CDC policy designs. Findings advance our understanding of CDC policy features from a cross-national perspective. Policymakers could incorporate these findings to empower older people in their respective societies

Evaluation of a savings-led family-based economic empowerment intervention for AIDS-affected adolescents in Uganda: A four-year follow-up on efficacy and cost-effectiveness

Background Children who have lost a parent to HIV/AIDS, known as AIDS orphans, face multiple stressors affecting their health and development. Family economic empowerment (FEE) interventions have the potential to improve these outcomes and mitigate the risks they face. We present efficacy and cost-effectiveness analyses of the Bridges study, a savings-led FEE intervention among AIDS-orphaned adolescents in Uganda at four-year follow-up. Methods Intent-to-treat analyses using multilevel models compared the effects of two savings-led treatment arms: Bridges (1:1 matched incentive) and BridgesPLUS (2:1 matched incentive) to a usual care control group on the following outcomes: self-rated health, sexual health, and mental health functioning. Total per-participant costs for each arm were calculated using the treatment-on-the-treated sample. Intervention effects and per-participant costs were used to calculate incremental cost-effectiveness ratios (ICERs). Findings Among 1,383 participants, 55% were female, 20% were double orphans. Mean age was 12 years at baseline. At 48-months, BridgesPLUS significantly improved self-rated health, (0.25, 95% CI 0.06, 0.43), HIV knowledge (0.21, 95% CI 0.01, 0.41), self-concept (0.26, 95% CI 0.09, 0.44), and self-efficacy (0.26, 95% CI 0.09, 0.43) and lowered hopelessness (-0.28, 95% CI -0.43, -0.12); whereas Bridges improved self-rated health (0.26, 95% CI 0.08, 0.43) and HIV knowledge (0.22, 95% CI 0.05, 0.39). ICERs ranged from $224 for hopelessness to$298 for HIV knowledge per 0.2 standard deviation change. Conclusions Most intervention effects were sustained in both treatment arms at two years post-intervention. Higher matching incentives yielded a significant and lasting effect on a greater number of outcomes among adolescents compared to lower matching incentives at a similar incremental cost per unit effect. These findings contribute to the evidence supporting the incorporation of FEE interventions within national social protection frameworks

TANF coverage, state TANF requirement stringencies, and child well-being

© 2015 Elsevier Ltd.Aim: After almost two decades since welfare reform, it is crucial to understand how Temporary Assistance to Needy Families (TANF), a US cash safety net program, has affected child well-being. This study investigated the potential effect of TANF coverage on child well-being, how different stringencies in state TANF policies on time limit and work requirements affect child well-being, and whether income or employment effects explain observed relationships. Data and methods: Data from the nationally-representative Survey on Income and Program Participation, 2004 and 2008 panels, provide a unique opportunity to observe child well-being at two time points. This study includes children who are not covered by TANF 12. months before the first time point and observe how TANF coverage between two time points affect child well-being. In order to rule out pre-existing difference between TANF-covered and non-covered groups, I use difference-in-difference and propensity score matching to compare individual-level changes over time. Results: TANF coverage may improve a family's daily routine, increase parents' educational expectations of their children, and decrease children's likelihood to repeat a grade, but TANF is not able to enhance child well-being in areas of cognitive stimulation, family interactions, and parenting stress reduction. Neither state TANF policy stringencies nor income and employment changes show significant differential influence on TANF's impact on child well-being. Recommendation: To improve the well-being of children in low-income families, social assistance programs need to go beyond financial assistance and workfare approaches and consider services that could better help parents cope with stress and provide a healthy, encouraging, and stimulating environment for their children.Link_to_subscribed_fulltex

Family economic strengthening and mental health functioning of caregivers for AIDS-affected children in rural Uganda

In sub-Saharan Africa, many extended families assume the role of caregivers for children orphaned by AIDS (AIDS-affected children). The economic and psychological stress ensued from caregiving duties often predispose caregivers to poor mental health outcomes. Yet, very few studies exist on effective interventions to support these caregivers. Using data from a randomized controlled trial called Suubi-Maka (N = 346), this paper examines whether a family economic strengthening intervention among families caring for AIDS-affected children (ages 12-14) in Uganda would improve the primary caregivers' mental health functioning. The Suubi-Maka study comprised of a control condition (n = 167) receiving usual care for AIDS-affected children, and a treatment condition (n = 179) receiving a family economic strengthening intervention, including matched savings accounts, and financial planning and management training to incentivize families to save money for education and/or family-level income generating projects. This paper uses data from baseline/pre-intervention (wave 1) interviews with caregivers and 12-month post-intervention initiation (wave 2). The caregiver's mental health measure adapted from previous studies in sub-Saharan Africa had an internal consistency of.88 at wave 1 and.90 at wave 2. At baseline, the two study groups did not significantly differ on caregiver's mental health functioning. However, at 12-month follow-up, multiple regression analysis located significant differences between the two study groups on mental health functioning. Specifically, following the intervention, caregivers in the treatment condition reported positive improvements on their mental health functioning, especially in the symptom areas of obsession-compulsion, interpersonal sensitivity, hostility, and psychoticism. Findings point to a need for programs and policies aimed at supporting caregivers of AIDS-affected children to begin to consider incorporating family-level economic strengthening components in their usual care protocols, especially in low-resource countries of sub-Saharan Africa. Economic empowerment programming may help enhance the well-being of caregivers and their families. © 2014 Taylor & Francis.Link_to_subscribed_fulltex

Health of Newly Arrived Immigrants in Canada and the United States: Differential Selection on Health

Canada and the U.S. are two major immigrant-receiving countries characterized by different immigration policies and health care systems. The present study examines whether immigrant health selection, or the "healthy immigrant effect", differs by destination and what factors may account for differences in immigrant health selection. We use 12 years of U.S. National Health Interview Survey and Canadian Community Health Survey data to compare the risks of overweight/obesity and chronic health conditions among new immigrants in the two countries. Results suggest a more positive health selection of immigrants to Canada than the U.S. Specifically, newly arrived U.S. immigrants are more likely to be overweight or obese and have serious chronic health conditions than their Canadian counterparts. The difference in overweight/obesity was explained by differences in source regions and educational levels of immigrants across the two countries. But this is not the case for serious chronic conditions. These results suggest that immigration-related policies can potentially shape immigrant health selection

Family economic empowerment and mental health among AIDS-affected children living in AIDS-impacted communities: Evidence from a randomised evaluation in southwestern Uganda

Objective: The authors examine whether an innovative family economic empowerment intervention addresses mental health functioning of AIDS-affected children in communities heavily impacted by HIV/AIDS in Uganda. Methods: A cluster randomised controlled trial consisting of two study arms, a treatment condition (n=179) and a control condition (n=118), was used to examine the impact of the family economic empowerment intervention on children's levels of hopelessness and depression. The intervention comprised matched children savings accounts, financial management workshops and mentorship. Data were collected at baseline and 12 months post-intervention. Results: Using multivariate analysis with several socioeconomic controls, the authors find that children in the treatment condition (receiving the intervention) report significant improvement in their mental health functioning. Specifically, the intervention reduces hopelessness and depression levels. On the other hand, children in the control condition (not receiving the intervention) report no changes on both measures. Conclusions: The findings indicate that children with poor mental health functioning living in communities affected by HIV/AIDS may benefit from innovative family economic empowerment interventions. As measures of mental health functioning, both hopelessness and depression have long-term negative psychosocial and developmental impacts on children. These findings have implications for public health programmes intended for long-term care and support of children living in resource poor AIDS-impacted communities.Link_to_subscribed_fulltex

Women's land ownership and risk of HIV infection in Kenya

Theory predicts that land ownership empowers women to avoid HIV acquisition by reducing their reliance on risky survival sex and enhancing their ability to negotiate safer sex. However, this prediction has not been tested empirically. Using a sample of 5511 women working in the agricultural sector from the 1998, 2003 and 2008-09 Kenya Demographic and Health Surveys, we examined the relationship between women's land ownership and participation in transactional sex, multiple sexual partnerships and unprotected sex, and HIV infection status. We controlled for demographic characteristics and household wealth, using negative binomial and logistic regression models. Women's land ownership wasassociated with fewer sexual partners in the past year (incidence rate ratio, 0.98; 95% confidence interval [CI], 0.95-1.00) and lower likelihood of engaging in transactional sex (odds ratio [OR], 0.67; 95% CI: 0.46-0.99), indicators of reduced survival sex, but was not associated with unprotected sex with casual partners (OR, 0.64; 95% CI, 0.35-1.18) or with unprotected sex with any partner among women with high self-perceived HIV risk (OR, 1.02; 95% CI, 0.57-1.84), indicating no difference in safer sex negotiation. Land ownership was also associated with reduced HIV infection among women most likely to engage in survival sex, i.e., women not under the household headship of a husband (OR, 0.40; 95% CI, 0.18-0.89), but not among women living in husband-headed households, for whom increased negotiation for safer sex would be more relevant (OR, 1.74; 95% CI, 0.92-3.29). These findings suggest that reinforcing women's land rights may reduce reliance on survival sex and serve as a viable structural approach to HIV prevention, particularly for women not in a husband's household, including unmarried women and female household heads. © 2014 Elsevier Ltd.Link_to_subscribed_fulltex

Unhealthy Assimilation or Persistent Health Advantage? A Longitudinal Analysis of Immigrant Health in the United States

Existing evidence on immigrant health assimilation, which is largely based on cross-sectional data, suggests that immigrants' initial health advantage erodes over time. This study uses longitudinal data to directly compare the self-rated health trajectories of immigrants and the native-born population. Data come from four panels of the Survey of Income and Program Participation (1996, 2001, 2004, and 2008), with each panel containing 2-4 years of health information. Results show that immigrants’ self-rated health remained stable during the period under study, but there was a concomitant decline in health for the native-born population. This result pointed to a persistent health advantage of immigrants during the period under study. The pattern held for immigrants of different length of residence and was especially salient for those originally from Latin America and Asia. Our findings that immigrants maintain their health advantage do not support the pattern of unhealthy assimilation commonly reported in cross-sectional studies