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PubMed1997

Medicare's disproportionate share adjustment and the cost of low-income patients.

We investigated whether or not hospitals have higher costs for inpatient care provided low-income Medicare patients, after controlling for other cost differences already accounted for by Medicare payments. We estimated differences in Prospective Payment System-adjusted costs and outlier-adjusted length of stay for low-income patients relative to matching non-low-income cases from the same hospital in 85 high-volume diagnosis-related groups (N = 1,247,670). Low-income Medicare patients do not have costlier hospital stays, although their stays are 2.5% longer. We conclude that disproportionate share payments are not justified on grounds of higher treatment costs.

Cost of Illness↗
PubMed2003

Assessment of cost-effectiveness of universal hepatitis B immunization in a low-income country with intermediate endemicity using a Markov model.

BACKGROUND/AIMS: Most countries with high hepatitis B (HB) virus endemicity and most high-income countries have introduced immunization programmes against this infection. However, several low-income countries with intermediate HB endemicity have not done so. We performed a cost-effectiveness analysis of universal childhood HB immunization in such countries using India as an example, since available data on this aspect are limited. METHODS: Marginal cost of every life-year and quality-adjusted life-year (QALY) gained with universal HB vaccination was calculated using a Markov model. Two types of analyses (including and excluding expenditure on treatment of long-term complications of HB infection) were done. Several sensitivity analyses and Monte-Carlo simulation were performed. RESULTS: Universal immunization reduced the HB carrier rate by 71%, and increased the number of years and QALY lived by a birth-cohort by 0.173 years (61.072 vs. 60.899 years) and 0.213 years (61.056 vs. 60.843 years), respectively. Marginal costs were US$16.27 per life-year gained and US$13.22 per QALY gained, much lower than annual per capita income. One-way sensitivity analysis and Monte-Carlo simulation confirmed the robustness of the conclusions. CONCLUSIONS: Universal HB immunization is highly cost-effective in low-income countries with intermediate endemicity rates.

Cost-Benefit Analysis↗
PubMed1998

Promoting successful breast feeding among women with a low income.

OBJECTIVE: To identify those factors which promote or discourage successful breast feeding in a sample of women with a low income. DESIGN: Qualitative research using in-depth, semi-structured interviews. SAMPLE: All women with a low income who were identified as having breast fed their latest baby at least once and who had delivered at a district general hospital in the south west of England from 17 September 1996 to 5 February 1997. FINDINGS: Three behavioural areas which determined whether or not women with a low income continued to breast feed were identified: individual and social environmental, baby and midwifery practice factors. In terms of individual and social environmental factors those women who continued to breast feed were more likely to have: positive attitudes; realistic expectations; greater levels of self-esteem; a supportive mother/friend; a partner who was not against breast feeding; and the ability to cope with the perceived temporary social isolation. In terms of baby factors those women who continued to breast feed had babies who were more likely to: have three- or four-hourly feeds; be perceived as a contented baby; and have gained weight. And finally, in terms of midwifery practice factors, those women who continued to breast feed were more likely to have: not been separated from their baby; not been given supplementary or complementary feeds; received good advice, especially with regard to positioning the baby at the breast; had greater continuity of midwifery input; had sufficient quality time with a midwife; and had the opportunity to solve problems with a community midwife's help. IMPLICATIONS FOR PRACTICE: Midwifery practice can be improved to promote successful breast feeding among women with a low income by: 1) creating realistic expectations and increasing women's confidence/desire to succeed in breast feeding; 2) providing good quality advice and support to mothers of newborn babies, particularly with regard to positioning the baby at the breast; 3) improving social-support networks available to breast-feeding mothers, perhaps through educating grandmothers (or partners) in breast-feeding matters.

Adolescent↗
PubMed1997

Age-specific education and income gradients in morbidity and mortality in a Canadian province.

While important age-related trends in the use of health care services over the past two decades in Canada have been well described, a comprehensive description of socioeconomic gradients in morbidity and mortality across age cohorts for a representative population has not been accomplished to date in Canada. The objective of this study was to describe age-specific socioeconomic differentials in mortality and morbidity for a representative sample of a single Canadian province. The study sample was formed from the linkage of individual respondent records in the 1986 census to vital statistics records and comprehensive records of health care utilization for a 5% sample of residents of the province of Manitoba. Using two measures of socioeconomic status derived from census responses, attained education and household income, individuals were stratified into age-specific quartile ranks. Based on diagnostic information contained on health care utilization records, the proportion of the sample in treatment during a 12-month observation period was calculated for 15 broadly defined categories of morbidity and tested for differences across socioeconomic quartiles. Mortality was inversely associated with both income and education quartile rank. In the analysis of morbidity, no association between socioeconomic status and treatment prevalence was observed in the majority, no association between socioeconomic status and treatment prevalence was observed in the majority of the 122 age- and disorder-specific strata tested. Of the observed associations, however, negative relationships were dominant, indicating a higher treatment prevalence among individuals of lower attained education or lower household income. Across the age course, negative relationships were most frequently present among young and middle aged adults, those aged 30-64, and were more consistently found for income than for education. The general findings of this study of a representative Canadian population support observations from other developed country settings that socioeconomic differences in relative rates of mortality and morbidity over the life course are greatest in the adult years.

Adolescent↗
PubMed1998

Living in a housing co-operative for low income women: issues of identity, environment and control.

The purpose of this study was to develop an understanding of how living on a low income affects the health of women and focused on the experiences of women living in a new housing co-operative built exclusively for unattached, low income women of middle age. Initially, the main focus of this study was the health beliefs, concerns, and practices of women living on a low income. As the study evolved, however, the experience of living in the housing co-operative was of such concern to the participants that the effects of housing on health came to have greater importance. A qualitative method was used based on Spradley's ethnographic method (Spradley, J. (1979). The ethnographic interview. Holt, Rinehart, and Winston, New York). Data included interviews with ten volunteer participants and field notes about these interviews and collection spanned a period of eight months. The major health issues that arose for the women focused around the concepts of the identity, environment and control. The women frequently mentioned aspects of the environment in regards to their health. The co-operative itself was an interesting environment with the potential to reduce the women's sense of isolation. The social context of the co-operative, however, was often cited as a source of stress rather than support. One of the most striking and unexpected findings of this study was that the women did not identify with one another. The women interviewed perceived themselves as a diverse group without a common identity. Finally, control emerged as a major theme underlining the women's perceptions of health. When asked to describe their lives, the women invariably began discussing coping strategies they used to manage on a low income. One woman actually made the connection between poverty and a lack of control by defining poverty as "having no options".

Adult↗
PubMedDate not supplied

Determinants of non-home-prepared food consumption in two low-income areas in Nairobi.

OBJECTIVE: Street foods are an important source of nutrients for poor urban residents. This study aimed to identify determinants of the proportion of daily energy provided by non-home-prepared foods. METHODS: A survey was conducted in a slum and a low- to middle-income area of Nairobi. The survey included 241 men and 254 women. Through a structured questionnaire, data on demographic and socioeconomic factors were collected and food intake was assessed with three standardized 24-hour recalls. A measure of socioeconomic status was constructed with principal component analysis. RESULTS: For women in the slum area, the presence of school-age children and distance to work were determinants of non-home-prepared food consumption, whereas employment status and distance to work were determinants for men in the slum area (P < 0.05). Having their own income and, for those employed, employment status were determinants for women in the low- to middle-income area, whereas socioeconomic status was the determinant for the men (P < 0.05). In the slum area, most non-home-prepared foods were derived from street foods, whereas in the low- to middle-income area, both kiosks and street foods were important sources of non-home-prepared foods. CONCLUSIONS: In the determinants of non-home-prepared energy consumption, we discerned a pattern from rather basic determinants to determinants of a more complicated nature with increasing socioeconomic level of the groups. Furthermore, a shift from street foods to kiosks as the main source of non-home-prepared foods consumed appeared with increasing socioeconomic levels.

Diet↗
PubMed2002

The syndromic approach to treatment of sexually transmitted diseases in low-income countries: issues, challenges, and future directions.

BACKGROUND: Sexually transmitted diseases (STDs) are a major cause of adult morbidity worldwide. In 1991, the World Health Organization (WHO) introduced the concept of the "syndromic approach" to managing sexually transmitted diseases in low-income countries, however, there has been some controversy regarding the ongoing use of this approach. OBJECTIVES: (1) To understand the use of the syndromic approach to managing sexually transmitted diseases in low-income countries, and to determine if evidence supports its continued use. (2) To help Canadian doctors understand the past STD management of immigrant patients from low-income countries, and evaluate the direct effect (if any) of such medical practices to the patient's health and perception of health in Canada. METHODS: Medline was searched under the key words "sexually transmitted diseases," "developing nations," and "syndrome," as well as "algorithms," "prevention and control," and "WHO." Research articles and data were also accessed from the Web sites of WHO, UNAIDS, Reproductive Health Online (JHSPH), and the Centers for Disease Control and Prevention (USA). Data were selected based on the relevance to the topic, and research articles assessed from a methodological perspective. Most research articles were of Level II-2 evidence or lower as described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam. RESULTS: In resource-poor countries, the use of the syndromic approach is appropriate for high-risk groups and for symptomatic individuals. However, it is still a poor screening approach when applied to asymptomatic cases, particularly in women. Risk scoring and simple laboratory tests help to increase the algorithmic sensitivity of the syndromic approach. CONCLUSION: Syndromic management involves making clinical decisions based on a patient's symptoms and signs. Until inexpensive, simple, and accurate STD diagnostics are developed and made available for use in low-income countries, a modified syndromic approach is the most feasible method of STD management in these countries. It is useful for Canadian physicians to be aware of this approach especially when caring for women from these countries.

Algorithms↗
PubMed2006

Inter-relationships of income, chronic energy deficiency, morbidity and hospitalization among adult male slum dwellers of Midnapore, West Bengal, India.

A cross-sectional study of 212 adult (>18 years) male slum dwellers (mean age=34.6+/-14.4 years) of Midnapore town, West Bengal, India, was undertaken to study the inter-relationships of chronic energy deficiency (CED), monthly family income (MFI), self-reported morbidity and hospitalization due to severe illness. The mean height, weight and body mass index (BMI) of the subjects were 160.0 cm, 50.8 kg and 19.9 kg/m2, respectively. The overall frequencies of CED (BMI<18.5 kg/m2), morbidity and hospitalization were 38.2%, 34.4% and 13.7%, respectively. Based on the WHO classification, the prevalence of CED among this population was high (20-39%), indicating a serious situation. Overall, MFI was significantly (p<0.01) positively correlated with BMI (r=0.21). Linear regression analyses showed that MFI had a significant impact (t=3.08; p<0.002) on BMI. Overall, MFI explained 3.9% variation in BMI. Subjects belonging to the lowest family income group (FIG I) had the lowest mean BMI (19.1 kg/m2) and the highest rate of CED (46.3%) and morbidity (36.6%). Those in the highest family income group (FIG III) had the largest mean BMI (20.8 kg/m2) and lowest rate of CED (30.2%) and morbidity (30.2%). The highest rate (18.9%) of hospitalization was found in this group. There were significant family income group differences in mean BMI (F=3.134, p<0.05). The frequency of morbidity (24.6%) and hospitalization (11.9%) was lowest among normal BMI individuals. Morbidity was significantly higher (chi2=11.92, p=0.0026) among CED (48.2%) subjects compared with normal BMI individuals (OR=2.85; CI=1.49-5.46). Similarly, compared with normal BMI subjects, morbidity was higher (38.5%; OR=1.92; 95% CI=0.50-7.18) among overweight subjects. Hospitalization was more common among CED subjects (16.1%; OR=1.42; CI=0.58-3.45) compared with normal BMI subjects. Similarly, the frequency of hospitalization was more among overweight individuals (15.4%; OR=1.35; 95% CI=0.0-7.59). In conclusion, this study provides evidence that the frequency of CED among this population is high, indicating a serious situation. Moreover there exists strong inter-relationships between BMI, CED, MFI and morbidity.

Adult↗
PubMed1999

Treatment of schizophrenia in low-income countries.

The introduction of the novel antipsychotics has had a major impact upon the treatment of schizophrenia. However, the greater acquisition costs of these drugs puts them beyond the reach of large sectors of the world's population. Consequently, the gap between the levels of care in high-income and low-income countries is likely to widen even further. Co-ordinated global action is necessary to ensure greater accessibility of these drugs. Cost-effectiveness studies in low-income countries need to be undertaken. The considerable evidence for improved safety and efficacy of low-dose compared to high-dose classical antipsychotics offers an alternative that could be implemented immediately in low-income countries.

Journal Article↗
PubMed2003

An examination of sociocultural factors associated with cervical cancer screening among low-income Latina immigrants of reproductive age.

The purpose of this study was threefold: 1) to examine whether low-income Latina immigrants were less likely to receive a Pap smear than low-income non-Latinas; 2) to examine ethnic differences regarding cervical cancer knowledge; and 3) to examine the sociocultural factors associated with cervical cancer screening among low-income Latina immigrants. Participants included 225 low-income women of reproductive age attending a WIC (Women, Infants, and Children) clinic (50% Latina immigrants and 50% non-Latinas). Latina immigrants were less educated, less likely to have health insurance, and more likely to be married or living with a partner than non-Latinas (ps<0.05). All non-Latinas had a Pap smear in the past compared to 81.3% of Latina immigrants (p<0.001). Latina immigrants displayed significantly less knowledge regarding cervical cancer than non-Latinas (ps<0.01). Latina immigrants tended to display culturally based knowledge and beliefs regarding cervical cancer and screening that may influence getting a Pap smear.

Adolescent↗
PubMed2006

Vitamin-mineral supplement use by low-income Brazilian pregnant adolescents and non-adolescents and the predictors for non-use.

OBJECTIVES: To determine (1) the intake of vitamin-mineral supplements by 855 low-income Brazilian pregnant adolescents and non-adolescents in three interviews (gestational ages < or =16, 20-26 and 30-36 weeks), (2) the relationship between vitamin-mineral supplementation and toxic exposure, and nutritional, psychological, socio-economic, demographic and obstetric characteristics of the women. DESIGN: Longitudinal cohort study. SETTING: Jundiaí city, São Paulo, Brazil. SUBJECTS: A total of 855 pregnant adolescents and non-adolescents who attended antenatal care from September 1997 to August 2000. METHODS: A general questionnaire was utilized three times in pregnancy (gestational ages < or =16, 20-26 and 30-36 weeks) to investigate the vitamin-mineral supplements ingested by the women, their smoking habit and alcohol intake, anthropometric measurements (pre-pregnancy and actual weight, height, mid-upper arm circumference) and psychological (anxiety, stress and distress), socio-economic (per capita income), demographic (education, age, marital status) and obstetric (gravidity) characteristics. The associations between vitamin-mineral supplementation and maternal characteristics were assessed in 12 multiple logistic regression models, stratifying the women by age and per capita income. RESULTS: Iron and vitamin C were the most ingested supplements by adolescents and non-adolescents, in the three interviews. Logistic regression analysis revealed that the maternal predictors for non-use of vitamin-mineral supplementation were acute anxiety and alcohol intake for adolescents, and low education, single without partner, distress (anxiety, depression, etc.) and stress for non-adolescents. CONCLUSIONS: These are important data to identify groups of low-income pregnant women in need of supplementation guidance and nutrition education. Stress/distress was a predictor for non-use of vitamin-mineral supplements for both adolescents and non-adolescents pregnant women.

Adolescent↗
PubMedDate not supplied

Polycyclic aromatic hydrocarbon exposures of children in low-income families.

Children in low-income families may have high exposures to polycyclic aromatic hydrocarbons (PAH). Such exposures could result from household proximity to heavy traffic or industrial sources, environmental tobacco smoke, contaminated house dust or soil, among others. The objectives of this study were: to establish methods for measuring total PAH exposure of children in low-income families, to estimate the PAH exposures of these children, and to estimate the relative importance of the environmental pathways for PAH exposure. Analytical methods to determine PAH in air, dust, soil, and food and to determine hydroxy-PAH in urine samples were evaluated and validated. A two-home pilot study was conducted in downtown Durham, North Carolina (NC) during February 1994. One smoker's and one nonsmoker's household, which had preschool children and income at or below the official U.S. poverty level, participated. A nine-home winter and a nine-home summer study were conducted in Durham and the NC Piedmont area during February 1995 and August 1995, respectively. A summer study in four smokers' homes was also conducted. In each of these studies, multimedia samples were collected and analyzed for PAH or hydroxy-PAH. Summary statistics, Pearson correlations, and analysis of variance were performed on the combined data from these four field studies. An effective screening method was established for recruiting low-income families. The field protocol involved measurements of three homes in 2-day periods. This protocol should be suitable for large-scale studies. The results showed that indoor PAH levels were generally higher than outdoor PAH levels. Higher indoor PAH levels were observed in the smokers' homes compared to nonsmokers' homes. Higher outdoor PAH levels were found in inner city as opposed to rural areas. The relative concentration trend for PAH in dust and soil was: house dust > entryway dust > pathway soil. The PAH concentrations in adults' food samples were generally higher than those in children's food samples. Children's potential daily doses of PAH were higher than those of adults in the same household, when intakes were normalized to body weights. Inhalation is an important pathway for children's exposure to total PAH because of the high levels of naphthalene present in both indoor and outdoor air. Dietary ingestion and nondietary ingestion pathways became more important for children's exposure to the B2 PAH (ranked as probable human carcinogens, B2 by the U.S. EPA's Integrated Risk System), most of which are of low volatility. The analysis of variance results showed that inner city participants had higher total exposure to B2 PAH than did rural participants.

Adult↗
PubMed2003

Transformation of Streptococcus pneumoniae relies on DprA- and RecA-dependent protection of incoming DNA single strands.

Seventy-five years after the discovery of transformation with Streptococcus pneumoniae, it is remarkable how little we know of the proteins that interact with incoming single strands in the early processing of transforming DNA. In this work, we used as donor DNA in transformation a radioactively labelled homologous fragment to examine the fate of the single-stranded (ssDNA) products of uptake in cells mutant for DprA or RecA, two proteins essential for transformation. Fifteen minutes after uptake, the labelling of specific chromosomal restriction fragments that demonstrated homologous integration in the wild type was not detected in dprA or recA cells, indicating that in the mutants incoming ssDNA could not be processed into recombinants. Investigation of the fate of donor label 1 min after uptake revealed that incoming ssDNA was immediately degraded in the absence of DprA or RecA. Our results demonstrate that incoming ssDNA requires active protection prior to the RecA-driven search for homology and that both DprA and RecA are needed for this protection.

Bacterial Proteins↗
PubMed2002

Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women.

BACKGROUND: Breastfeeding can ameliorate some of the complex health issues faced by low-income families. Women who breastfeed and their infants have lower health care costs compared with those who formula feed. Increasing the duration of breastfeeding is recognized as a national priority, particularly for low-income women. This community-based randomized clinical trial involving low-income mothers compared usual care with an intervention comprising hospital and home visits, and telephone support by a community health nurse/peer counselor team for 6 months after delivery. METHODS: Forty-one women were recruited after delivery of a full-term singleton infant and randomly assigned to intervention or usual care groups. RESULTS: Women receiving the community health intervention breastfed longer than the women receiving usual care. The infants in the intervention group had fewer sick visits and reported use of fewer medications than infants in the usual care group. The intervention cost ($301/mother) was partially offset by cost savings on formula and health care. CONCLUSIONS: Community health nurse and peer counselor support can increase breastfeeding duration in low-income women, and has the potential to reduce total costs including the cost of support.

Adolescent↗
PubMed1995

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?

BACKGROUND: Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS: We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS: Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS: Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.

Adult↗
PubMed2003

Low-income consumers' attitudes and behaviour towards access, availability and motivation to eat fruit and vegetables.

OBJECTIVE: To determine low-income consumers' attitudes and behaviour towards fruit and vegetables, in particular issues of access to, affordability of and motivation to eat fruit and vegetables. DESIGN AND SETTING: Questionnaire survey mailed to homes owned by a large UK housing association. PARTICIPANTS: Participants were 680 low-income men and women, aged 17-100 years. RESULTS: Age, employment, gender, smoking and marital status all affected attitudes towards access, affordability and motivation to eat fruit and vegetables. Few (7%) participants experienced difficulty in visiting a supermarket at least once a week, despite nearly half having no access to a car for shopping. Fruit and vegetables were affordable to this low-income group in the amounts they habitually bought; purchasing additional fruits and vegetables was seen as prohibitively expensive. Less than 5% felt they had a problem with eating healthily and yet only 18% claimed to eat the recommended 5 or more portions of fruit and vegetables every day. CONCLUSIONS: Supported by research, current UK Government policy is driven by the belief that low-income groups have difficulties in access to and affordability of fruit and vegetables. Findings from this particular group suggest that, of the three potential barriers, access and affordability were only a small part of the 'problem' surrounding low fruit and vegetable consumption. Thus, other possible determinants of greater consequence need to be identified. We suggest focusing attention on motivation to eat fruit and vegetables, since no dietary improvement can be achieved if people do not recognise there is a problem.

Adolescent↗
PubMed2002

Food budget standards and dietary adequacy in low-income families.

Budget standards are specified baskets of goods and services which, when priced, can represent predefined living standards. 'Low cost but acceptable' (LCA) is a minimum income standard, adequate to provide warmth and shelter, a healthy and palatable diet, social necessities, social integration, avoidance of chronic stress and the maintenance of good health (physical, mental and social) in a context of free access to good-quality health care, good-quality education and social justice. The LCA food budget standard identifies a basket of foods and corresponding menus which provides (for a given household composition) a palatable diet that is consistent with prevailing cultural norms, and that satisfies existing criteria for health in relation to dietary reference values, food-based dietary guidelines and safe levels of alcohol consumption. Two previous studies that explored the relationship between diet and food expenditure in low-income households suggested that the amount spent on food was a good predictor of dietary adequacy, growth and health in children. The current paper will focus on diet and measures of deprivation in 250 low-income households in London. Households were screened for material deprivation (e.g. no car, no fixed line telephone, in receipt of Income Support) using a doorstep questionnaire. Diet was assessed using four 24 h recalls based on the 'triple pass' method. Expenditure on food and other aspects of household circumstances were assessed by face-to-face interview. Food expenditure in these households was characterized in relation to food budget standards. Further analyses explored the relationships between food expenditure and dietary adequacy, growth in children and measures of deprivation.

Budgets↗
PubMed2002

Geographic inequalities in the availability of government-subsidized rental housing for low-income older persons in Florida.

PURPOSE: This article investigates the extent to which government-subsidized affordable rental units available to low-income older persons are unequally and unfairly distributed throughout Florida's counties. DESIGN AND METHODS: Primary data sources from the U.S. Department of Housing and Urban Development and the U.S. Census were analyzed using two location inequality statistical measures: quintile analysis and the Dissimilarity Index. Three comparison standards measuring the county locations of the community-wide low-income elderly and nonelderly populations were used to judge whether these patterns are geographically unfair. RESULTS: Compared with the overall locations of Florida's low-income older population, elder-occupied government-subsidized rental housing units are concentrated in fewer counties. On the basis of several standards, these affordable housing units are judged to be unfairly located, resulting in most of the state's low-income elderly population living in counties that are underserved by these accommodations. IMPLICATIONS: The findings offer other states and local areas guideposts to assess and compare the extent of geographic inequality and unfairness in the availability of their affordable senior housing opportunities. Why these inequalities exist and their implications for older persons are researchable questions.

Demography↗