Papers

2022
Rokicki, S., McGovern, M., Von Jaglinsky, A., & Reichman, N. (2022). Depression in the Postpartum Year and Life Course Economic Trajectories. American Journal of Preventive Medicine , 62 (2), 165–173.
McGovern, M., & Rokicki, S. (2022). The Great Recession, Household Income, and Children’s Test Scores. Review of Income and Wealth , Forthcoming. review_of_income_and_wealth_-_2022_-_mcgovern_-_the_great_recession_household_income_and_children_s_test_scores.pdf
McGovern, M., Rokicki, S., & Reichman, N. E. (2022). Maternal depression and economic well-being: A quasi-experimental approach. Social Science & Medicine , 305, 115017. Publisher's VersionAbstract
Maternal depression is associated with adverse impacts on the health of women and their children. However, further evidence is needed on the extent to which maternal depression impacts women's economic well-being and how unmeasured confounders affect estimates of this relationship. In this study, we aimed to measure the association between maternal depression and economic outcomes (income, employment, and material hardship) over a 15-year time horizon. We conducted longitudinal analyses using the Fragile Families and Child Wellbeing Study, an urban birth cohort study in the United States. We assessed the potential contribution of time-invariant unmeasured confounders using a quasi-experimental approach and also investigated the role of persistent versus transient depressive symptoms on economic outcomes up to 15 years after childbirth. In models that adjusted for time-invariant unmeasured confounders, maternal depression was associated with not being employed (an adjusted risk difference of 3 percentage points (95% CI 0.01 to 0.05)), and experiencing any material hardship (an adjusted risk difference of 14 percentage points (95% CI 0.12 to 0.16)), as well as with reductions in the ratio of household income to poverty by 0.10 units (95% CI -0.16 to −0.04) and annual household income by \$2114 (95% CI -\$3379 to -\$850). Impacts at year 15 were strongest for those who experienced persistent depression. Results of our study strengthen the case for viewing mental health support services as interventions that can also foster economic well-being, and highlight the importance of including economic impacts in assessments of the cost-effectiveness of mental health interventions.
mcgovern_ssm_2022.pdf
2021
Wang, P., McGovern, M., & Togo, Y. (2021). Geographic diversity in authorship of HIV randomized control trial publications. AIDS , 35 (14), 2407–2409. Publisher's Version
2020
Bloom, D., Chen, S., Kuhn, M., McGovern, M., Oxley, L., & Prettner, K. (2020). The Economic Burden of Chronic Diseases: Estimates and Projections for China, Japan, and South Korea. Journal of the Economics of Ageing , 17, 100163. Publisher's VersionAbstract
We propose a novel framework to analyse the macroeconomic impact of non-communicable diseases. We incorporate measures of disease prevalence into a human capital augmented production function, which enables us to determine the economic costs of chronic health conditions in terms of foregone gross domestic product (GDP). Unlike previously adopted frameworks, this approach allows us to account for i) variations in human capital for workers in different age groups, ii) mortality and morbidity effects of non-communicable diseases, and iii) the treatment costs of diseases. We apply our methodology to China, Japan, and South Korea, and estimate the economic burden of chronic conditions in five domains (cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, and mental health conditions). Overall, total losses associated with these diseases over the period 2010-2030 are $7.7 trillion for China (measured in real USD with the base year 2010), $3.5 trillion for Japan, and $1 trillion for South Korea.
Bloom_JOEA_2018.pdf
2019
McGovern, M. (2019). Life cycle origins of pre-retirement financial status: Insights from birth cohort data. In D. Bloom (Ed.), Live Long and Prosper? The Economics of Ageing Populations (pp. 74–80) . London, UK, CEPR Press. Publisher's Version
McGovern, M. (2019). How much does birth weight matter for child health in developing countries? Estimates from siblings and twins. Health Economics , 28 (1), 3-22. Publisher's VersionAbstract
About 200 million children globally are not meeting their growth potential, and as a result will suffer the consequences in terms of future outcomes. I examine the effects of birth weight on child health and growth using information from 66 countries. I account for missing data and measurement error using instrumental variables and adopt an identification strategy based on siblings and twins. I find a consistent effect of birth weight on mortality risk, stunting, wasting, and coughing, with some evidence for fever, diarrhoea, and anaemia. Bounds analysis indicates that coefficients may be substantially underestimated due to mortality selection. Improving the pre‐natal environment is likely to be important for helping children reach their full potential.
McGovern_HE_2019.pdf
Klein, N., Kneib, T., Marra, G., Radice, R., Rokicki, S., & McGovern, M. (2019). Mixed binary-continuous copula regression models with application to adverse birth outcomes. Statistics in Medicine , 38 (3), 413-436. Publisher's VersionAbstract
Bivariate copula regression allows for the flexible combination of two arbitrary, continuous marginal distributions with regression effects being placed on potentially all parameters of the resulting bivariate joint response distribution. Motivated by the risk factors for adverse birth outcomes, many of which are dichotomous, we consider mixed binary-continuous responses that extend the bivariate continuous framework to the situation where one response variable is discrete (more precisely binary) while the other response remains continuous. Utilizing the latent continuous representation of binary regression models, we implement a penalized likelihood based approach for the resulting class of copula regression models and employ it in the context of modelling gestational age and the presence/absence of low birth weight. The analysis demonstrates the advantage of the flexible specification of regression impacts including nonlinear effects of continuous covariates and spatial effects. Our results imply that racial and spatial inequalities in the risk factors for infant mortality are even greater than previously suggested.
ms_wps_charms_18_06.pdf
2018
Krishna, A., Mejía-Guevara, I., McGovern, M., Aguayo, V. M., & Subramanian, S. V. (2018). Trends in Inequalities in Child Stunting in South Asia. Maternal & Child Nutrition , S4 (14), e12517. Publisher's VersionAbstract
We analysed socio-economic inequalities in stunting in South Asia and investigated disparities associated with factors at the individual, caregiver, and household levels (poor dietary diversity, low maternal education, and household poverty). We used time-series analysis of data from 55,459 children ages 6–23 months from Demographic and Health Surveys in Bangladesh, India, Nepal, and Pakistan (1991–2014). Logistic regression models, adjusted for age, sex, birth order, and place of residency, examined associations between stunting and multiple types of socio-economic disadvantage. All countries had high stunting rates. Bangladesh and Nepal recorded the largest reductions—2.9 and 4.1 percentage points per year, respectively—compared to 1.3 and 0.6 percentage points in India and Pakistan, respectively. Socio-economic adversity was associated with increased risk of stunting, regardless of disadvantage type. Poor children with inadequate diets and with poorly educated mothers experienced greater risk of stunting. Although stunting rates declined in the most deprived groups, socio-economic differences were largely preserved over time and in some cases worsened, namely, between wealth quintiles. The disproportionate burden of stunting experienced by the most disadvantaged children and the worsening inequalities between socio-economic groups are of concern in countries with substantial stunting burdens. Closing the gap between best and worst performing countries, and between most and least disadvantaged groups within countries, would yield substantial improvements in stunting rates in South Asia. To do so, greater attention needs to be paid to addressing the social, economic, and political drivers of stunting with targeted efforts towards the populations experiencing the greatest disadvantage and child growth faltering.
McGovern_2018_Maternal_Child_Nutrition.pdf
McGovern, M., Canning, D., & Bärnighausen, T. (2018). Accounting for non-response bias using participation incentives and survey design: An application using gift vouchers. Economics Letters , 171, 239-244. Publisher's VersionAbstract
Standard corrections for missing data rely on the strong and generally untestable assumption of missing at random. Heckman-type selection models relax this assumption, but have been criticized because they typically require a selection variable which predicts non-response but not the outcome of interest, and can impose bivariate normality. In this paper we illustrate an application using a copula methodology which does not rely on bivariate normality. We implement this approach in data on HIV testing at a demographic surveillance site in rural South Africa which are affected by non-response. Randomized incentives are the ideal selection variable, particularly when implemented ex ante to deal with potential missing data. However, elements of survey design may also provide a credible method of correcting for non-response bias ex post. For example, although not explicitly randomized, allocation of food gift vouchers during our survey was plausibly exogenous and substantially raised participation, as did effective survey interviewers. Based on models with receipt of a voucher and interviewer identity as selection variables, our results imply that 37% of women in the population under study are HIV positive, compared to imputation-based estimates of 28%. For men, confidence intervals are too wide to reject the absence of non-response bias. Consistent results obtained when comparing different selection variables and error structures strengthen these conclusions. Our application illustrates the feasibility of the selection model approach when combined with survey metadata.
McGovern_EL_2018.pdf
Rokicki, S., & McGovern, M. (2018). Unequal opportunities for play? How children spend their time in Ireland. Children's Research Digest , 5 (2), 11-19. Publisher's Version Rokicki_McGovern_CRN_2018.pdf
Bloom, D., Chen, S., & McGovern, M. (2018). The Economic Burden of Non-Communicable Diseases and Mental Health Conditions: Results for Costa Rica, Jamaica, and Peru. Pan American Journal of Public Health , 42 (e18). Publisher's VersionAbstract
Objectives
We extend the World Health Organization’s (WHO) EPIC model and apply it to analyze the macroeconomic impact of non-communicable diseases (NCDs) and mental health conditions in Costa Rica, Jamaica, and Peru.

Methods
The EPIC model quantifies the impact of NCDs and mental health conditions on aggregate output solely through the effect of chronic conditions on labor supply due to mortality. In contrast, the expanded EPIC-H Plus framework also incorporates reductions in effective labor supply due to morbidity and negative effects of health expenditure on output via the diversion of productive savings and reduced capital accumulation. We apply this methodology to Costa Rica, Jamaica, and Peru, and estimate the economic burden of all NCDs and mental health conditions in these countries.

Results
Overall, our results show total losses associated with these NCDs and mental health conditions over the period 2015–2030 of $81.96 billion 2015 USD for Costa Rica, $18.45 billion for Jamaica, and $477.33 billion for Peru. The costliest condition varies by country.

Conclusions
These results indicate that the economic impact of NCDs and mental health conditions is substantial and that interventions to reduce the prevalence of chronic conditions in Latin American countries are likely to be highly cost beneficial.
mcgovern_pajph.pdf
2017
Harling, G., Moyo, S., McGovern, M. E., Mabaso, M., Marra, G., Bärnighausen, T., & Rehle, T. (2017). National South African HIV prevalence estimates robust despite substantial test non-participation. South African Medical Journal , 107 (7), 590–594. Publisher's VersionAbstract

Background

South African (SA) national HIV seroprevalence estimates are of crucial policy relevance in the country, and for the worldwide HIV response. However, the most recent nationally representative HIV test survey in 2012 had 22% test non-participation, leaving the potential for substantial bias in current seroprevalence estimates, even after controlling for selection on observed factors.Objective. To re-estimate national HIV prevalence in SA, controlling for bias due to selection on both observed and unobserved factors in the 2012 SA National HIV Prevalence, Incidence and Behaviour Survey.

Methods

We jointly estimated regression models for consent to test and HIV status in a Heckman-type bivariate probit framework. As selection variable, we used assigned interviewer identity, a variable known to predict consent but highly unlikely to be associated with interviewees’ HIV status. From these models, we estimated the HIV status of interviewed participants who did not test.

Results

Of 26 710 interviewed participants who were invited to test for HIV, 21.3% of females and 24.3% of males declined. Interviewer identity was strongly correlated with consent to test for HIV; declining a test was weakly associated with HIV serostatus. Our HIV prevalence estimates were not significantly different from those using standard methods to control for bias due to selection on observed factors: 15.1% (95% confidence interval (CI) 12.1 - 18.6) v. 14.5% (95% CI 12.8 - 16.3) for 15 - 49-year-old males; 23.3% (95% CI 21.7 - 25.8) v. 23.2% (95% CI 21.3 - 25.1) for 15 - 49-year-old females.

Conclusion

The most recent SA HIV prevalence estimates are robust under the strongest available test for selection bias due to missing data. Our findings support the reliability of inferences drawn from such data.

McGovern_SAJM.pdf
McGovern, M., Krishna, A., Aguayo, V., & Subramanian, S. V. (2017). A Review of the Evidence Linking Child Stunting to Economic Outcomes. International Journal of Epidemiology , 46 (4), 1171–1191.Abstract
To understand the full impact of stunting in childhood it is important to consider the long run effects of undernutrition on the outcomes of adults who were affected in early life. Focusing on the costs of stunting provides a means of evaluating the economic case for investing in childhood nutrition. We review the literature on the association between stunting in childhood and economic outcomes in adulthood. At the national level, we also evaluate the evidence linking stunting to economic growth. Throughout, we consider RCTs, quasi-experimental approaches, and observational studies. Long-run evaluations of two randomized nutrition interventions indicate substantial returns to the programs (a 25% and 46% increase in wages for those affected as children). Cost-benefit analyses of nutrition interventions report a median return of 17.9:1 per child. Assessing the wage premium associated with adult height, we find that a 1 centimeter increase in stature is associated with a 4% increase in wages for men and a 6% increase in wages for women in our preferred set of studies which attempt to address unobserved confounding and measurement error. In contrast, the evidence on the association between economic growth on stunting is mixed. Countries with high rates of stunting, such as those in South Asia and sub-Saharan Africa, should consider interventions and policies targeted at improving undernutrition as cost-beneficial investments which expand the economic opportunities of their children, better allowing them and their countries to reach their full potential. However, economic growth as a policy will only be effective at reducing the prevalence of stunting when increases in national income are directed at improving the diets of children, addressing gender inequalities and strengthening the status of women, improving sanitation, and reducing poverty.
McGovern_IJE_Stunting.pdf
Marra, G., Radice, R., Bärnighausen, T., Wood, S., & McGovern, M. (2017). A Simultaneous Equation Approach to Estimating HIV Prevalence with Non-Ignorable Missing Responses. Journal of the American Statistical Association , 518 (12), 484–496.Abstract
Estimates of HIV prevalence are important for policy in order to establish the health status of a country's population and to evaluate the effectiveness of population-based interventions and campaigns. However, participation rates in testing for surveillance conducted as part of household surveys, on which many of these estimates are based, can be low. HIV positive individuals may be less likely to participate because they fear disclosure, in which case estimates obtained using conventional approaches to deal with missing data, such as imputation-based methods, will be biased. We develop a Heckman-type simultaneous equation approach which accounts for non-ignorable selection, but unlike previous implementations, allows for spatial dependence and does not impose a homogeneous selection process on all respondents. In addition, our framework addresses the issue of separation, where for instance some factors are severely unbalanced and highly predictive of the response, which would ordinarily prevent model convergence. Estimation is carried out within a penalized likelihood framework where smoothing is achieved using a parametrization of the smoothing criterion which makes estimation more stable and efficient. We provide the software for straightforward implementation of the proposed approach, and apply our methodology to estimating national and sub-national HIV prevalence in Swaziland, Zimbabwe and Zambia.
McGovern_JASA.pdf
Rockli, K., Perkins, J., Krishna, A., Aguayo, V., McGovern, M., & Subramanian, S. V. (2017). Understanding the Association Between Stunting and Child Development in Low- and Middle-Income Countries: Next Steps for Research and Intervention. Social Science & Medicine , 193, 101–109.Abstract
Stunting affects approximately 25% of children under age five globally (i.e. 156 million pre-school age children). In this review, evidence of a relationship between stunting and child development in low- and middle-income countries is summarized, and issues for further research are discussed. We focus on studies measuring low height-for-age caused by experiences of chronic nutritional deprivation among children less than 5 years old as the exposure and gross and cognitive abilities, fine motor skills, psychosocial competencies, or schooling and learning milestones as outcomes. This review highlights three key findings. Firstly, the variability in child development tools and metrics used among studies and the differences in timing and frequency of the assessments complicate comparisons across study findings. Secondly, despite methodological differences and differential associations, considerable evidence from across many countries, supports an association between stunting and poor child development. Effect sizes differ by development domain with greater effects shown for cognitive/schooling outcomes. How stunting influences child development, which domains of child development are more affected, and how the various domains of child development influence one another require further research. Finally, there is some evidence of positive synergistic interaction between nutrition and stimulation on child development. However, understanding how best to improve child developmental outcomes – either through nutrition programs or integrated nutrition and psychosocial stimulation – is a key area of further inquiry. Given that nearly 40% of children under age five suffer from loss of developmental potential - for which stunting is likely one of the key risk factors - reductions in stunting could have tremendous implications for child development and human capital formation, particularly in low- and middle-income countries.
McGovern_SSM.pdf
2016
McGovern, M., Herbst, K., Tanser, F., Mutevedzi, T., Canning, D., Gareta, D., Pillay, D., et al. (2016). Do Gifts Increase Consent to Home-based HIV Testing? A Difference-in-Differences Study in Rural KwaZulu-Natal, South Africa. International Journal of Epidemiology , 45 (6), 2100–2109. Publisher's VersionAbstract

Background

Despite the importance of HIV testing for controlling the HIV epidemic, testing rates remain low. Efforts to scale-up testing coverage and frequency in hard-to-reach and at-risk populations commonly focus on home-based HIV testing. This study evaluates the effect of a gift (a food voucher for families, worth US$ 5) on consent rates for home-based HIV testing.


Methods

We use data on 18,478 men and women who participated in the 2009 and 2010 population-based HIV surveillance carried out by the Wellcome Trust Africa Centre for Health and Population Studies in rural KwaZulu-Natal, South Africa. Our quasi-experimental difference-in-differences approach controls for unobserved confounding in estimating the causal effect of the intervention on HIV testing consent rates.


Results

Allocation of the gift to a family in 2010 increased the probability of family members consenting to test in 2010 by 25 percentage points (95% CI 21-30; p<0.001). The intervention effect persisted, slightly attenuated, in the year following the intervention (2011), further increasing intervention value for money.


Conclusions

In HIV hyperendemic settings a gift can be highly effective at increasing consent rates for home-based HIV testing. Given the importance of HIV testing for treatment uptake and individual health, as well as for HIV treatment-and-prevention strategies and for monitoring the population impact of the HIV response, gifts should be considered as a supportive intervention for HIV testing initiatives where consent rates have been low.

McGovern_IJE_Gifts.pdf
Noelke, C., McGovern, M., Stern, A., Corsi, D., Pescador-Jimenez, M., Wing, I. S., & Berkman, L. (2016). Increasing Ambient Temperature Reduces Subjective Well-Being. Environmental Research , 151, 124–129. Publisher's VersionAbstract
This study examines the impact of ambient temperature on emotional well-being in the U.S. population aged 18+. The U.S. is an interesting test case because of its resources, technology and variation in climate across different areas, which also allows us to examine whether adaptation to different climates could weaken or even eliminate the impact of heat on well-being. Using survey responses from 1.9 million Americans over the period from 2008 to 2013, we estimate the effect of temperature on well-being from exogenous day-to-day temperature variation within respondents’ area of residence and test whether this effect varies across areas with different climates. We find that increasing temperatures significantly reduce well-being. Compared to average daily temperatures in the 50–60 °F (10–16 °C) range, temperatures above 70 °F (21 °C) reduce positive emotions (e.g. joy, happiness), increase negative emotions (e.g. stress, anger), and increase fatigue (feeling tired, low energy). These effects are particularly strong among less educated and older Americans. However, there is no consistent evidence that heat effects on well-being differ across areas with mild and hot summers, suggesting limited variation in heat adaptation.
McGovern_ER.pdf
McGovern, M. E. (2016). Progress and the Lack of Progress in Addressing Infant Health and Infant Health Inequalities in Ireland during the 20th Century. Journal of the Statistical and Social Inquiry Society of Ireland. Publisher's VersionAbstract
There is a growing literature which documents the importance of early life environment for outcomes across the life cycle. Research, including studies based on Irish data, demonstrates that those who experience better childhood conditions go on to be wealthier and healthier adults. Therefore, inequalities at birth and in childhood shape inequality in wellbeing in later life, and the historical evolution of the mortality and morbidity of children born in Ireland is important for understanding the current status of the Irish population. In this paper, I describe these patterns by reviewing the existing literature on infant health in Ireland over the course of the 20th century. Up to the 1950s, infant mortality in Ireland (both North and South) was substantially higher than in other developed countries, with a large penalty for those born in urban areas. The subsequent reduction in this penalty, and the sustained decline in infant death rates, occurred later than would be expected from the experience in other contexts. Using records from the Rotunda Lying-in Hospital in Dublin, I discuss sources of disparities in stillbirth in the early 1900s. Despite impressive improvements in death rates since that time, a comparison with those born at the end of the century reveals that Irish children continue to be born unequal. Evidence from studies which track people across the life course, for example research on the returns to birthweight, suggests that the economic cost of this early life inequality is substantial.
McGovern_JSSISI.pdf
Journal of the Statistical and Social Inquiry Society of Ireland, Vol. XLV 2015-6, pp. 117-145.
2015
McGovern, M., Marra, G., Radice, R., Canning, D., Newall, M. - L., & Bärnighausen, T. (2015). Adjusting HIV Prevalence Estimates for Non-participation: an Application to Demographic Surveillance. Journal of the International AIDS Society , 18 (1), 19954. Publisher's VersionAbstract
Introduction: HIV testing is a cornerstone of efforts to combat the HIV epidemic, and testing conducted as part of surveillance provides invaluable data on the spread of infection and the effectiveness of campaigns to reduce the transmission of HIV. However, participation in HIV testing can be low, and if respondents systematically select not to be tested because they know or suspect they are HIV positive (and fear disclosure), standard approaches to deal with missing data will fail to remove selection bias. We implemented Heckman-type selection models, which can be used to adjust for missing data that are not missing at random, and established the extent of selection bias in a population-based HIV survey in an HIV hyperendemic community in rural South Africa.

Methods: We used data from a population-based HIV survey carried out in 2009 in rural KwaZulu-Natal, South Africa. In this survey, 5565 women (35%) and 2567 men (27%) provided blood for an HIV test. We accounted for missing data using interviewer identity as a selection variable which predicted consent to HIV testing but was unlikely to be independently associated with HIV status. Our approach involved using this selection variable to examine the HIV status of residents who would ordinarily refuse to test, except that they were allocated a persuasive interviewer. Our copula model allows for flexibility when modelling the dependence structure between HIV survey participation and HIV status.

Results: For women, our selection model generated an HIV prevalence estimate of 33% (95% CI 27–40) for all people eligible to consent to HIV testing in the survey. This estimate is higher than the estimate of 24% generated when only information from respondents who participated in testing is used in the analysis, and the estimate of 27% when imputation analysis is used to predict missing data on HIV status. For men, we found an HIV prevalence of 25% (95% CI 15–35) using the selection model, compared to 16% among those who participated in testing, and 18% estimated with imputation. We provide new confidence intervals that correct for the fact that the relationship between testing and HIV status is unknown and requires estimation.

Conclusions: We confirm the feasibility and value of adopting selection models to account for missing data in population-based HIV surveys and surveillance systems. Elements of survey design, such as interviewer identity, present the opportunity to adopt this approach in routine applications. Where non-participation is high, true confidence intervals are much wider than those generated by standard approaches to dealing with missing data suggest.
McGovern_JIAS_19954_20841_1_pb.pdf

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