Multi-Level Socioenvironmental Contributors to Childhood Asthma in New York City: a Cluster Analysis

Traffic-related air pollution in marginalized neighborhoods: a community perspective

OBJECTIVES

Marginalized communities are exposed to higher levels of traffic-related air pollution (TRAP) than the general population. TRAP exposure is linked to pulmonary toxicity, neurotoxicity, and cardiovascular toxicity often through mechanisms of inflammation and oxidative stress. Early life exposure to TRAP is also implicated in higher rates of asthma in these same communities. There is a critical need for additional epidemiological, in vivo, and in vitro studies to define the health risks of TRAP exposure affecting the most vulnerable groups to set strict, protective air pollution standards in these communities.

MATERIALS AND METHODS

A literature review was conducted to summarize recent findings (2010-2024) concerning TRAP exposure and toxic mechanisms that are relevant to the most affected underserved communities.

CONCLUSIONS

Guided by the perspectives of NYC community scientists, this contemporary review of toxicological and epidemiological studies considers how the exposome could lead to disproportionate exposures and health effects in underserved populations.

Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study

OBJECTIVES

Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use.

DESIGN

Multicenter retrospective cohort study.

SETTING

Administrative data from the Pediatric Health Information Systems (PHIS) database.

PATIENTS

All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47).

CONCLUSIONS

Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.

The longitudinal association between asthma severity and physical fitness by neighborhood factors among New York City public school youth

PURPOSE

This paper aims to examine the association between asthma severity and one-year lagged fitness in New York City Public school youth by neighborhood opportunity.

METHODS

Using the Child Opportunity Index 2.0 and individual-level repeated measures NYC Office of School Health (OSH) fitness surveillance data (2010-2018), we ran multilevel mixed models stratified by neighborhood opportunity, adjusting for sex, race/ethnicity, grade level, poverty status, and time. Asthma severity was based on a physician-completed Asthma Medication Administration Form (MAF) from each school year and drawn from the Automated Student Health Record (ASHR).

RESULTS

Across all youth in grades 4-12 (n = 939,598; 51.7 % male; 29.9 % non-Hispanic Black, 39.3 % Hispanic; 70.0 % high poverty), lower neighborhood opportunity was associated with lower subsequent fitness. Youth with severe asthma and very low and low neighborhood opportunity had the lowest 1-year lagged fitness z-scores - 0.24 (95 % CI, -0.34 to -0.14) and - 0.26 (95 % CI, -0.32 to -0.20), respectively, relative to youth with no asthma and very high opportunity.

CONCLUSIONS

An inverse longitudinal relationship between asthma severity and subsequent fitness was observed. Study findings have implications for public health practitioners to promote physical activity and improved health equity for youth with asthma, taking neighborhood factors into account.

How are mental representations of asthma triggers and symptoms related to interpersonal risk perceptions? A psychometric investigation of caregivers of children with asthma

OBJECTIVE

Parents and guardians (hereafter caregivers) make decisions for their children's medical care. However, many caregivers of children with asthma struggle to understand their child's illness. We used the psychometric paradigm to investigate how caregivers conceptualize, or mentally represent, asthma triggers and symptoms and how these representations are linked to perceived asthma exacerbation risk.

METHODS

We asked 377 caregivers of children with asthma across the U.S. to rate 20 triggers or 20 symptoms along 15 characteristics. Caregivers also indicated their perceived risk of their child having an asthma exacerbation (hereafter interpersonal risk perceptions). Using principal components analysis, we extracted key dimensions underlying caregivers' ratings on the characteristics. Then we related the triggers' and symptoms' scores on the dimensions to caregivers' interpersonal risk perceptions.

RESULTS

Interpersonal risk perceptions were higher for triggers with high ratings for the dimensions severe and relevant, and negative affect-yet manageable, but not chronic-yet unpredictable. Risk perceptions were also higher for symptoms with high ratings for the dimensions severe and unpredictable, and relevant and common, but not self-blame or manageable despite unknown cause.

CONCLUSION

By identifying key dimensions underlying caregivers' mental representations of asthma triggers and symptoms, these findings can inform a new approach to asthma education.

Risk of Frailty in Survivors of Childhood Cancer: The Role of Socioenvironmental Factors

The identification of frailty among relatively young survivors of childhood cancer has led to a growing body of work aimed at examining potential risk factors and interventions to decrease its burden in this population. In the accompanying article, Schwartz and colleagues present their findings regarding the association between neighborhood characteristics and frailty in survivors of childhood cancer and show that survivors living in resource poor neighborhoods had increased odds of frailty compared with those in resource-rich neighborhoods. This work further supports the need for focused educational initiatives and nutrition and exercise interventions to improve survivors' quality of health. See related article by Schwartz et al., p. 1021.

Protecting Children's Health: Asthma and Climate Change

ABSTRACT

Children are particularly vulnerable to the impacts of climate change. Their lungs are developing, making children with asthma especially susceptible to temperature extremes, variations in precipitation, poor air quality, and changes in pollen and flora. Structural and social determinants of health, such as racism and poverty, that disproportionately affect children of color are linked to higher rates of asthma and negative effects of climate change. These factors lead to increased absences from school and social activities, loss of work for caregivers, and increased health care costs, thus negatively affecting children, their families, and the greater community. Nurses must support caregivers and children to link climate change to asthma care, be involved in health education; climate change mitigation and adaptation strategies and policies; and develop the evidence to address climate change and asthma strategies. We address the impacts of climate change on children with asthma and nursing adaptation responses.

Social Vulnerability and Risk of Nonrelapse Mortality After Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

Risk of nonrelapse mortality (NRM) after hematopoietic cell transplantation (HCT) is high. Patient-level clinical prediction models such as the HCT-comorbidity index (HCT-CI) help identify those at increased risk for NRM, but the independent contribution of social determinants of health on HCT outcomes is not well characterized.

METHODS

This study included 1602 patients who underwent allogeneic HCT between 2013 and 2019 at City of Hope. Census tract-level social vulnerability was measured using the social vulnerability index (SVI). Fine-Gray multivariable regression evaluated the association between SVI and 1-year NRM. Subgroup analysis examined risk of NRM across combined SVI and HCT-CI categories and by race and ethnicity.

RESULTS

Cumulative incidence of 1-year NRM after HCT was 15.3% (95% confidence interval [CI] = 13.6% to 17.1%). In multivariable analysis, patients in the highest SVI tertile (highest social vulnerability) had a 1.4-fold risk (subdistribution hazard ratio [sHR] = 1.36, 95% CI = 1.04 to 1.78) of NRM compared with individuals in the lower tertiles; patients in the highest SVI tertile who also had elevated (≥3) HCT-CI scores had the highest risk (sHR = 1.81, 95% CI = 1.26 to 2.58) of 1-year NRM (reference: lower SVI tertiles and HCT-CI < 3). High social vulnerability was associated with risk of 1-year NRM in Asian (sHR = 2.03, 95% CI = 1.09 to 3.78) and Hispanic (sHR = 1.63, 95% CI = 1.04 to 2.55) but not non-Hispanic White patients.

CONCLUSIONS

High social vulnerability independently associated with 1-year NRM after HCT, specifically among minority populations and those with a high comorbidity burden at HCT. These findings may inform targeted approaches for needs assessment during and after HCT, allowing for timely interventions to improve health outcomes in at-risk patients.

The effects of the historical practice of residential redlining in the United States on recent temporal trends of air pollution near New York City schools

BACKGROUND

In the 1930's the United States (US) sponsored Home Owners' Loan Corporation (HOLC) created maps that determined risk for mortgage lending based on the racial and ethnic composition of neighborhoods leading to disinvestment in "redlined" or highest risk neighborhoods. This historical practice has perpetuated racial and economic segregation, and health disparities, that persist today. Interventions near schools where children spend large portions of the day, could impact large groups of children but schools are an often-overlooked environment for exposure. Despite a declining trend of ambient pollution in New York City (NYC) between 1998 and 2012, little is known about differences in air quality improvement near schools by historical redlining neighborhood status. Our objective was to examine if recent temporal trends of air pollution near NYC public schools differed in historically redlined neighborhoods.

METHODS

We examined annual average street-level concentrations of combustion-related air pollutants (black carbon (BC), particulate matter (PM_2.5), nitrogen dioxide (NO₂), and nitric oxide (NO)), within a 250-m radius around schools using NYC Community Air Survey land-use regression models (n = 1,462). Year of monitoring, historical redlining (binary), and summer ozone were included in multivariable linear regression using generalized estimating equation models. Average annual percent change (APC) in pollutant concentration was calculated. Models were further stratified by historical redlining and a multiplicative interaction term (year of monitoring × historical redlining) was used to assess effect modification.

RESULTS

Overall, there was a decreasing trend of BC (APC = -4.40%), PM_2.5 (-3.92%), NO₂ (-2.76%), and NO (-6.20%) during the 10-year period. A smaller reduction of BC, PM_2.5 and NO was observed in redlined neighborhoods (n = 722), compared to others (n = 740): BC (APC: -4.11% vs -4.69%; P_interaction < 0.01), PM_2.5 (-3.82% vs -4.11%; P_interaction < 0.01), and NO (-5.73% vs -6.67%; P_interaction < 0.01). Temporal trends of NO₂ did not differ by historical redlining (P_interaction = 0.60).

CONCLUSIONS

Despite significant reductions in annual average pollution concentrations across NYC, schools in historically redlined neighborhoods, compared to others, experienced smaller decrease in pollution, highlighting a potential ongoing ramification of the discriminatory practice.

Housing environments and asthma outcomes within population-based samples of adults and children in NYC

Exposure to indoor environmental risk factors is associated with patterns of asthma morbidity. In this study, we assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). We used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma ("ever asthma") and experiencing a past-year asthma attack. We further examined whether associations were modified by smoking status (among adults), smoking within the home (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.35, 2.84), and past-year asthma attack (OR = 2.24; 95% CI 1.21,4.18). Living in rental assistance housing was also significantly associated with ever asthma (OR = 1.75; 95% CI 1.16, 2.66). Associations between public or rental assistance housing and ever asthma were marginally non-significant among children. Associations between living in public or rental assistance housing and ever asthma were more pronounced among ever smokers than among never smokers. Housing environments remain important predictors of both pediatric and adult asthma morbidity. Associations between living in subsidized housing and asthma outcomes among adults are most apparent among ever smokers.

In-home environmental exposures predicted from geospatial characteristics of the built environment and electronic health records of children with asthma

PURPOSE

Children may be exposed to numerous in-home environmental exposures (IHEE) that trigger asthma exacerbations. Spatially linking social and environmental exposures to electronic health records (EHR) can aid exposure assessment, epidemiology, and clinical treatment, but EHR data on exposures are missing for many children with asthma. To address the issue, we predicted presence of indoor asthma trigger allergens, and estimated effects of their key geospatial predictors.

METHODS

Our study samples were comprised of children with asthma who provided self-reported IHEE data in EHR at a safety-net hospital in New England during 2004-2015. We used an ensemble machine learning algorithm and 86 multilevel features (e.g., individual, housing, neighborhood) to predict presence of cockroaches, rodents (mice or rats), mold, and bedroom carpeting/rugs in homes. We reduced dimensionality via elastic net regression and estimated effects by the G-computation causal inference method.

RESULTS

Our models reasonably predicted presence of cockroaches (area under receiver operating curves [AUC] = 0.65), rodents (AUC = 0.64), and bedroom carpeting/rugs (AUC = 0.64), but not mold (AUC = 0.54). In models adjusted for confounders, higher average household sizes in census tracts were associated with more reports of pests (cockroaches and rodents). Tax-exempt parcels were associated with more reports of cockroaches in homes. Living in a White-segregated neighborhood was linked with lower reported rodent presence, and mixed residential/commercial housing and newer buildings were associated with more reports of bedroom carpeting/rugs in bedrooms.

CONCLUSIONS

We innovatively applied a machine learning and causal inference mixture methodology to detail IHEE among children with asthma using EHR and geospatial data, which could have wide applicability and utility.

Evidence of the Relationship between Social Vulnerability and the Spread of COVID-19 in Urban Spaces

Modeling the social-spatial structure of urban spaces can facilitate the development of guidelines aimed at curbing the spread of the COVID-19 pandemic while also acting as an instrument that helps decision-making concerning mitigation policies. The modeling process starts with categorization of urban spaces based on the concept of social vulnerability. A model is created based on this concept and the theory of analysis of social areas. Statistical techniques of factor analysis and geostatistics are applied. This generates a map of social differentiation that, when related to data on the evolution of the contagion, generates a multidimensional model of social vulnerability. The application of this model towards people (social structure) and the environment where they live (spatial structure) is specified. Our model assumes the uniqueness of cities, and it is intended to be a broadly applicable model that can be extrapolated to other urban areas if pertinent revisions are made. Our work demonstrates that aspects of the social and urban structures may be validly used to analyze and explain the spatial spread of COVID-19.

Effect Evaluation of Electronic Health PDCA Nursing in Treatment of Childhood Asthma with Artificial Intelligence

Asthma in children has a long duration and is prone to recurring attacks. Children will feel chest tightness, shortness of breath, cough, and difficulty breathing when they are onset, which has a serious impact on their health. Clinical nursing is of great significance in the treatment of childhood asthma. At present, the electronic health PDCA nursing model is widely used in clinical nursing as a common and effective nursing method. Therefore, it is very important to evaluate the efficacy of the PDCA nursing model in the treatment of childhood asthma. With the development of artificial intelligence, artificial intelligence can be used to evaluate the effect of the PDCA nursing model in the treatment of childhood asthma. The BP network can effectively perform data training and discrimination, but its training efficiency is low, and it is easily affected by initial weights and thresholds. Aiming at this defect, this work uses the genetic simulated annealing (GSA) algorithm to improve it. In view of the problems that the genetic algorithm falls into local minimum and simulated annealing algorithm has a slow convergence speed, the improved genetic simulated annealing algorithm is used to optimize the BP neural network, and an improved genetic simulated annealing BP network (IGSA-BP) is proposed. The algorithm not only reduces the problem that the BP network has an influence on initial weight and threshold on the algorithm but also improves the population diversity and avoids falling into local optimum by improving the crossover and mutation probability formula and improving Metropolis criterion. The proposed method has more efficient performance.