The Effects of Exposure to Better Neighborhoods on Children: New Evidence from the Moving to Opportunity Experiment

Free school meals and cognitive ability: Evidence from China's student nutrition improvement plan

The China Student Nutrition Improvement Plan (SNIP) covers 40.6 million students in the compulsory education stage, accounting for 42% of all students enrolled in rural compulsory education in 2021. This paper utilizes the county-by-county rollout of the SNIP and estimates the effect of this nutritional intervention on students' cognitive outcomes. We find that SNIP increases math test scores but has a statistically insignificant effect on verbal achievement. The effect is greater for middle school students and children from disadvantaged families. The SNIP affects the cognitive performance of students by improving their health status, increasing school attendance, fostering good study habits, raising educational expectations, and improving the human capital of peers.

Poor housing quality and the health of newborns and young children

This study uses linked administrative data on live births, hospital stays, and census records for children born in Hungary between 2006 and 2011 to examine the relationship between poor housing quality and the health of newborns and children aged 1-2 years. We show that poor housing quality, defined as lack of access to basic sanitation and exposure to polluting heating, is not a negligible problem even in a high-income EU country like Hungary. This is particularly the case for disadvantaged children, 20-25% of whom live in extremely poor-quality homes. Next, we provide evidence that poor housing quality is strongly associated with lower health at birth and a higher number of days spent in inpatient care at the age of 1-2 years. These results indicate that lack of access to basic sanitation, hygiene, and non-polluting heating and their health impacts cannot be considered as the exclusive problem for low- and middle-income countries. In high-income countries, there is also a need for public policy programs that identify those affected by poor housing quality and offer them potential solutions to reduce the adverse effects on their health.

Individual and regional differences in the effects of school racial segregation on Black students' health

Background

School racial segregation in the US has risen steadily since the 1990s, propelled by Supreme Court decisions rolling back the legacy of Brown v. Board. Quasi-experimental research has shown this resegregation harms Black students' health. However, whether individual or family characteristics (e.g., higher family incomes) are protective against segregation's health harms-or whether segregation is more damaging in regions of the US with fewer public sector investments-remains unclear. We leverage the quasi-random timing of school districts being released from Brown-era integration plans to examine heterogeneity in the association between resegregation and Black students' health.

Methods & findings

We took an instrumental variables approach, using the timing of integration order releases as an instrument for school segregation and analyzing a pre-specified list of theoretically-motivated modifiers in the Panel Study of Income Dynamics. In sensitivity analyses, we fit OLS models that directly adjusted for relevant covariates. Results suggest resegregation may have been particularly harmful in the South, where districts resegregated more quickly after order releases. We find little evidence that the effects of school segregation differed across family income, gender, or age.

Conclusion

The end of court-ordered integration threatens the health of Black communities-especially in the US South. Modestly higher incomes do not appear protective against school segregation's harms. Research using larger samples and alternative measures of school segregation-e.g., between districts, instead of within districts-may further our understanding of segregation's health effects, especially in Northern states.

The long-term health effects of childhood exposure to social and economic policies: A scoping review

While numerous studies have found a relationship between social and economic policies and short-term health outcomes, fewer studies have explored the long-term health effects of these policies. Given the important association between childhood circumstances and health in adulthood, long-term population health consequences should be considered when designing social and economic policies. This review summarizes the existing literature on the long-term effects of childhood exposure to social and economic policies on adult health, summarizes the findings, the methods employed, and indicates areas for future research. The review process followed the JBI scoping review protocol and PRISMA-ScR reporting guidelines. The search was conducted in three electronic databases (Web of Science, Pub Med, and SCOPUS), and focused on peer-reviewed manuscripts that studied the effects of policy exposures during childhood on health in adulthood. A total of 3471 articles were collected from the databases and 18 were identified as meeting the eligibility criteria. The most commonly studied policies were safety-net policies (N = 6), followed by education policies (N = 5), civil rights policies (N = 3), government investments (N = 3), and child labor laws (N = 1). The health outcomes varied and included chronic conditions, mental health, mortality, and self-rated health. The studies also overwhelmingly employed causal inference techniques (N = 13), including difference-in-differences study designs and instrumental variable analysis. Most studies found long-term positive effects of policies that provided extra resources to historically under-resourced populations, or policies that aimed to increase equality of opportunity. However, there were some studies with null or mixed findings, especially when examining the long-term health effects of education reform. More literature is needed on this important topic, and now is the time to capitalize on longer follow-up periods in currently available data.

Residential mobility and persistently depressed voting among disadvantaged adults in a large housing experiment

This study examines the impact of residential mobility on electoral participation among the poor by matching data from Moving to Opportunity, a US-based multicity housing-mobility experiment, with nationwide individual voter data. Nearly all participants in the experiment were Black and Hispanic families who originally lived in high-poverty public housing developments. Notably, the study finds that receiving a housing voucher to move to a low-poverty neighborhood decreased adult participants' voter participation for nearly two decades-a negative impact equal to or outpacing that of the most effective get-out-the-vote campaigns in absolute magnitude. This finding has important implications for understanding residential mobility as a long-run depressant of voter turnout among extremely low-income adults.

Racialized economic segregation and inequities in treatment initiation and survival among patients with metastatic breast cancer

PURPOSE

Racialized economic segregation, a form of structural racism, may drive persistent inequities among patients with breast cancer. We examined whether a composite area-level index of racialized economic segregation was associated with real-world treatment and survival in metastatic breast cancer (mBC).

METHODS

We conducted a retrospective cohort study among adult women with mBC using a US nationwide electronic health record-derived de-identified database (2011-2022). Population-weighted quintiles of the index of concentration at the extremes were estimated using census tract data. To identify inequities in time to treatment initiation (TTI) and overall survival (OS), we employed Kaplan-Meier methods and estimated hazard ratios (HR) adjusted for clinical factors.

RESULTS

The cohort included 27,459 patients. Compared with patients from the most privileged areas, those from the least privileged areas were disproportionately Black (36.9% vs. 2.6%) or Latinx (13.2% vs. 2.6%) and increasingly diagnosed with de novo mBC (33.6% vs. 28.9%). Those from the least privileged areas had longer median TTI than those from the most privileged areas (38 vs 31 days) and shorter median OS (29.7 vs 39.2 months). Multivariable-adjusted HR indicated less timely treatment initiation (HR 0.87, 95% CI 0.83, 0.91, p < 0.01) and worse OS (HR 1.19, 95% CI 1.13, 1.25, p < 0.01) among those from the least privileged areas compared to the most privileged areas.

CONCLUSION

Racialized economic segregation is a social determinant of health associated with treatment and survival inequities in mBC. Public investments directly addressing racialized economic segregation and other forms of structural racism are needed to reduce inequities in cancer care and outcomes.

Assessing social disparities in inpatient vs. outpatient arthroplasty: a in-state database analysis

INTRODUCTION

Given the growing emphasis on patient outcomes, including postoperative complications, in total joint arthroplasty (TJA), investigating the rise of outpatient arthroplasty is warranted. Concerns exist over the safety of discharging patients home on the same day due to increased readmission and complication rates. However, psychological benefits and lower costs provide an incentive for outpatient arthroplasty. The influence of social determinants of health disparities on outpatient arthroplasty remains unexplored. One metric that assesses social disparities, including the following individual components: socioeconomic status, household composition, minority status, and housing and transportation, is the Social Vulnerability Index (SVI). As such, we aimed to compare: (1) mean overall SVI and mean SVI for each component and (2) risk factors for total complications between patients undergoing inpatient and outpatient arthroplasty.

METHODS

Patients who underwent TJA between January 1, 2022 and December 31, 2022 were identified. Data were drawn from the Maryland State Inpatient Database (SID). A total of 7817 patients had TJA within this time period. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). The mean SVI was compared between inpatient and outpatient procedures for each themed score. The SVI identifies communities that may need support cause by external stresses on human health based on four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. The SVI uses the United States Census data to rank census tracts for each individual theme, as well as an overall social vulnerability score. The higher the SVI, the more social vulnerability, or resources needed to thrive in that area. Multivariate logistic regression analyses were performed to identify independent risk factors for total complications following TJA after controlling for risk factors and patient comorbidities. Total complications included: infection, aseptic loosening, dislocation, arthrofibrosis, mechanical complication, pain, and periprosthetic fracture.

RESULTS

Patients who had inpatient arthroplasty had higher overall SVI scores (0.45 vs. 0.42, P < 0.001). The SVI scores were higher for patients who had inpatient arthroplasty for socioeconomic status (0.36 vs. 0.32, P < 0.001), minority status and language (0.76 vs. 0.74, P < 0.001), and housing and transportation (0.53 vs. 0.50, P < 0.001) compared to outpatient arthroplasty, respectively. There was no difference between inpatient and outpatient arthroplasty for household composition and disability (0.41 vs. 0.41, P = 0.99). When controlling for comorbidities, inpatient arthroplasty [Odds Ratio (OR) 1.91, 95% Confidence Interval (CI) 1.23-2.95, P = 0.004], hypertension (OR 2.11, 95% CI 1.23-3.62, P = 0.007), and housing and transportation (OR 2.00, 95% CI 1.17-3.42, P = 0.012) were independent risk factors for total complications.

CONCLUSION

Inpatient arthroplasty was associated with increased social disparities across several components of deprivation as well as an independent risk factor total complications following TJA. To the best of our knowledge, this study is the first to examine the negative repercussions of inpatient arthroplasty through the lens of social disparities and can target specific areas for intervention.

Childhood Violence, High School Academic Environment, and Adult Alcohol Use Among Latinas and Black Women: A Structural Equation Modeling Study

OBJECTIVE

Young Latinas and Black women drink less than women of other racial/ethnic groups but experience more alcohol-related problems in midlife. This study aims to identify modifiable factors to prevent adult onset of alcohol use disorder (AUD) in this population.

METHODS

Data were collected at six time points as part of the Harlem Longitudinal Development Study from 365 Latinas (47%) and Black (53%) women (mean age at time 1 = 14, standard deviation 1.3). Structural equation modeling was used to test hypothesized pathways from childhood physical and sexual abuse to AUD via depressive mood, anxiety disorders, and somatic complaints in the 20s. We also tested the moderation effect of the high school academic environment by including in the structural equation model two latent variable interaction terms between the school environment and each of the abuse variables.

RESULTS

Childhood physical and sexual abuse was positively associated with depressive mood, anxiety disorders, and somatic complaints when participants were in the 20s. Depressive mood mediated childhood abuse and AUD when women were in the 30s. The high school academic environment attenuated the effect of physical, but not sexual abuse, on depressive mood (β = -0.59, B = -9.38, 95% CI [-14.00, -4.76]), anxiety symptoms (β = -0.61, B = -14.19, 95% CI [-21.76, -6.61]), appetite loss (β = -0.41, B = -10.52, 95% CI [-15.61, -5.42]), and sleeplessness (β = -0.50, B = -9.56, 95% CI [-13.95, -5.17]) in the early 20s.

CONCLUSIONS

Our findings underscore the need to invest in early violence prevention interventions and in education to ensure equitable access to quality, academically oriented, and safe schools.

Practical causal mediation analysis: extending nonparametric estimators to accommodate multiple mediators and multiple intermediate confounders

Mediation analysis is appealing for its ability to improve understanding of the mechanistic drivers of causal effects, but real-world data complexities challenge its successful implementation, including (i) the existence of post-exposure variables that also affect mediators and outcomes (thus, confounding the mediator-outcome relationship), that may also be (ii) multivariate, and (iii) the existence of multivariate mediators. All three challenges are present in the mediation analysis we consider here, where our goal is to estimate the indirect effects of receiving a Section 8 housing voucher as a young child on the risk of developing a psychiatric mood disorder in adolescence that operate through mediators related to neighborhood poverty, the school environment, and instability of the neighborhood and school environments, considered together and separately. Interventional direct and indirect effects (IDE/IIE) accommodate post-exposure variables that confound the mediator-outcome relationship, but currently, no readily implementable nonparametric estimator for IDE/IIE exists that allows for both multivariate mediators and multivariate post-exposure intermediate confounders. The absence of such an IDE/IIE estimator that can easily accommodate both multivariate mediators and post-exposure confounders represents a significant limitation for real-world analyses, because when considering each mediator subgroup separately, the remaining mediator subgroups (or a subset of them) become post-exposure intermediate confounders. We address this gap by extending a recently developed nonparametric estimator for the IDE/IIE to allow for easy incorporation of multivariate mediators and multivariate post-exposure confounders simultaneously. We apply the proposed estimation approach to our analysis, including walking through a strategy to account for other, possibly co-occurring intermediate variables when considering each mediator subgroup separately.

Annual Research Review: Neuroimmune network model of depression: a developmental perspective

Depression is a serious public health problem, and adolescence is an 'age of risk' for the onset of Major Depressive Disorder. Recently, we and others have proposed neuroimmune network models that highlight bidirectional communication between the brain and the immune system in both mental and physical health, including depression. These models draw on research indicating that the cellular actors (particularly monocytes) and signaling molecules (particularly cytokines) that orchestrate inflammation in the periphery can directly modulate the structure and function of the brain. In the brain, inflammatory activity heightens sensitivity to threats in the cortico-amygdala circuit, lowers sensitivity to rewards in the cortico-striatal circuit, and alters executive control and emotion regulation in the prefrontal cortex. When dysregulated, and particularly under conditions of chronic stress, inflammation can generate feelings of dysphoria, distress, and anhedonia. This is proposed to initiate unhealthy, self-medicating behaviors (e.g. substance use, poor diet) to manage the dysphoria, which further heighten inflammation. Over time, dysregulation in these brain circuits and the inflammatory response may compound each other to form a positive feedback loop, whereby dysregulation in one organ system exacerbates the other. We and others suggest that this neuroimmune dysregulation is a dynamic joint vulnerability for depression, particularly during adolescence. We have three goals for the present paper. First, we extend neuroimmune network models of mental and physical health to generate a developmental framework of risk for the onset of depression during adolescence. Second, we examine how a neuroimmune network perspective can help explain the high rates of comorbidity between depression and other psychiatric disorders across development, and multimorbidity between depression and stress-related medical illnesses. Finally, we consider how identifying neuroimmune pathways to depression can facilitate a 'next generation' of behavioral and biological interventions that target neuroimmune signaling to treat, and ideally prevent, depression in youth and adolescents.

If Opportunity Knocks: Understanding Contextual Factors' Influence on Cognitive Systems

Central to the Research Domain Criteria (RDoC) framework is the idea that RDoC constructs, which vary dimensionally by individual, are heavily influenced by contextual factors. Perhaps chief among these contextual factors is structural opportunity - the quality of resources available to a child as they grow. The aim of this study is to understand the impact of access to opportunity during childhood on three central RDoC cognitive systems constructs: language, visual perception, and attention. These constructs were measured using clinical data from psychological evaluations of youth ages 4-18 years (N = 16,523; Mage = 10.57, 62.3% male, 55.3% White). Structural opportunity was measured using the geocoded Child Opportunity Index 2.0 (COI), a composite score reflecting 29 weighted indicators of access to the types of neighborhood conditions that help children thrive. Findings indicate that, controlling for demographic and socioeconomic factors, greater access to opportunity is associated with significantly stronger cognitive skills across all three constructs. However, opportunity uniquely explains the largest proportion of the variance in language skills (8.4%), compared to 5.8% of the variance in visual processing skills and less than 2% of the variance in attention. Further, a moderating effect of age was found on the relation between COI and language skills, suggesting that the longer children remain exposed to lower levels of opportunity, the lower their language skills tend to be. Understanding how opportunity impacts cognitive development allows clinicians to offer better tailored recommendations to support children with cognitive systems deficits, and will support policy recommendations around access to opportunity.

Place-Based Child Opportunity at Birth and Child Development from Infancy to Age 4

OBJECTIVE

The objective of this study was to evaluate whether the children's neighborhood quality, as a measure of place-based social determinants of health, is associated with the odds of developmental delay and developmental performance up to the age of 4 years.

STUDY DESIGN

Mothers of 5702 children from the Upstate KIDS Study, a longitudinal population-based cohort of children born from 2008 through 2010, provided questionnaire data and a subset of 573 children participated in a clinic visit. The Child Opportunity Index 2.0 was linked to home census tract at birth. Probable developmental delays were assessed by the Ages and Stages Questionnaire up to 7 times between 4 and 36 months, and developmental performance was assessed via the Battelle Developmental Inventory at the age of 4 years.

RESULTS

In unadjusted models, higher neighborhood opportunity was protective against developmental delays and was associated with slightly higher development scores at age 4. After adjusting for family-level confounding variables, 10-point higher Child Opportunity Index (on a 100-point scale) remained associated with a lower odds of any developmental delay (OR = .966, 95% CI = .940-.992), and specifically delays in the personal-social domain (OR = .921, 95% CI = .886-.958), as well as better development performance in motor (B = 0.79, 95% CI = 0.11-1.48), personal-social (B = 0.64, 95% CI = 0.003-1.28), and adaptive (B = 0.69, 95% CI = 0.04-1.34) domains at age 4.

CONCLUSIONS

Community-level opportunities are associated with some aspects of child development prior to school entry. Pediatric providers may find it helpful to use neighborhood quality as an indicator to inform targeted developmental screening.

The influence of socio-economic status on child temperament and psychological symptom profiles

The influence of socio-economic status (SES) on child temperament and psychological symptoms was examined using a nationally representative sample in Singapore. Data were available for 2169 children from 1987 families. Caregivers' reports were obtained on children aged 4-6. SES was operationalized as an aggregation of household income per capita, parental education level and housing type. Compared to their counterparts from higher SES families, children from low-SES families tended to exhibit (a) higher negative affectivity but lower effortful control, and (b) higher internalizing and externalizing symptoms. In addition, children with a 'resilient' temperamental profile (i.e. low negative affectivity and high effortful control) were more likely to come from families with much higher SES, relative to children with other profiles. Children with high internalizing symptoms tended to come from low-SES backgrounds, regardless of their externalizing symptoms. Among children with low internalizing symptoms, those with high externalizing symptoms came from lower SES backgrounds compared to those with low externalizing symptoms. Parental warmth and distress mediated the association between SES and child temperament and symptom profiles, with the exception of distress in the SES-temperament link. These findings supported the family stress model and highlighted the novel perspective of SES's influence on configurations of child temperament and symptom characteristics.

The importance of community resources for breastfeeding

BACKGROUND

Breastfeeding has long-lasting effects on children's cognition, behavioral, mental and physical health. Previous research shows parental characteristics (e.g., education, race/ethnicity, income level) are associated with breastfeeding initiation and duration. Further, research shows significant variation in access to community resources by race/ethnicity. It is unclear how community resources may impact breastfeeding practices and how this might intersect with maternal race/ethnicity.

METHODS

This study combined nationally-representative data from the Study of Attitudes and Factors Effecting Infant Care (SAFE), which surveyed US mothers immediately after the infant's birth and at two to six months of infant age, with the Child Opportunity Index (COI) 2.0, a census tract measure of community resources associated with child development, to explore the association between community resources and breastfeeding initiation and whether this varies based on maternal race/ethnicity and country of birth. The SAFE Study used a stratified, two-stage, clustered design to obtain a nationally representative sample of mothers of infants, while oversampling Hispanic and non-Hispanic (NH) Black mothers. The SAFE study enrolled mothers who spoke English or Spanish across 32 US birth hospitals between January 2011 and March 2014.

RESULTS

After accounting for individual characteristics, mothers residing in the highest-resourced communities (compared to the lowest) had significantly greater likelihood of breastfeeding. Representation in higher-resourced communities differed by race/ethnicity. Race/ethnicity did not significantly moderate the association between community resources and breastfeeding. In examining within race/ethnic groups, however, community resources were not associated with non-US born Black and Hispanic mothers' rates of breastfeeding, while they were with US born Black and Hispanic mothers.

CONCLUSIONS

Findings suggest that even health behaviors like breastfeeding, which we often associate with individual choice, are connected to the community resources within which they are made. Study implications point to the importance of considering the impact of the contextual factors that shape health and as a potential contributor to understanding the observed race/ethnicity gap.

Unveiling early childhood health inequities by age five through the national neighborhood equity index and the early development instrument

There is growing public urgency to close equity gaps in health and development by addressing inequities at multiple levels of children's developmental ecosystems. Current measurement strategies obscure the dynamic structural and relational patterns of oppression, adversity, and disadvantage that children can experience in their local intimate developmental ecosystem, as well as the leverage points that are necessary to change them. The purpose of this study is to examine the relationship between a universally available measure of neighborhood socio-economic context, the National Neighborhood Equity Index (NNEI), and a population measure of early child development and well-being, the Early Development Instrument (EDI). Data from a convenience sample of 144,957 kindergarteners in neighborhoods across the US demonstrate that children living in neighborhoods with more equity barriers are more likely to be on vulnerable developmental trajectories than those who reside in neighborhoods without any equity barriers. A multi-dimensional measurement approach that incorporates both the EDI and the NNEI can be used to quantify ethnoracialized patterns of structural disadvantage during critical periods of health development. These measures can inform community action to intervene early in the lifecourse to optimize children's health development trajectories at a population level.

The Effect of the Earned Income Tax Credit on Physical and Mental health-Results from the Atlanta Paycheck Plus Experiment

Policy Points The Paycheck Plus randomized controlled trial tested a fourfold increase in the Earned Income Tax Credit (EITC) for single adults without dependent children over 3 years in New York and Atlanta. In New York, the intervention improved economic, mental, and physical health outcomes. In Atlanta, it had no economic benefit or impact on physical health and may have worsened mental health. In Atlanta, tax filing and bonus receipt were lower than in the New York arm of the trial, which may explain the lack of economic benefits. Lower mental health scores in the treatment group were driven by disadvantaged men, and the study sample was in good mental health.

CONTEXT

The Paycheck Plus experiment examined the effects of an enhanced Earned Income Tax Credit (EITC) for single adults on economic and health outcomes in Atlanta, GA and New York City (NYC). The NYC study was completed two years prior to the Atlanta study and found mental and physical benefits for the subgroups that responded best to the economic incentives provided. In this article, we present the findings from the Atlanta study, in which the uptake of the treatment (tax filings and EITC bonus) were lower and economic and health benefits were not observed.

METHODS

Paycheck Plus Atlanta was an unblinded randomized controlled trial that assigned n = 3,971 participants to either the standard federal EITC (control group) or an EITC supplement of up to $2,000 (treatment group) for three tax years (2017-2019). Administrative data on employment and earnings were obtained from the Georgia Department of Labor and survey data were used to examine validated measures of health and well-being.

FINDINGS

In Atlanta, the treatment group had significantly higher earnings in the first project year but did not have significantly higher cumulative earnings than the control group overall (mean difference = $1,812, 95% CI = -150, 3,774, p = 0.07). The treatment group also had significantly lower scores on two measures of mental health after the intervention was complete: the Patient Health Questionnaire 8 (mean difference = 0.19, 95% CI = 0.06, 0.32, p = 0.005) and the Kessler 6 (mean difference = 0.15, 95% CI = 0.03, 0.27, p = 0.012). Secondary analyses suggested these results were driven by disadvantaged men, but the study sample was in good mental health.

CONCLUSIONS

The EITC experiment in Atlanta was not associated with gains in earnings or improvements in physical or mental health.

Community Level Correlates of COVID-19 Booster Vaccine Hesitancy in the United States: A Cross-Sectional Analysis

Introduction: Evidence exists that individual-level sociodemographic factors contribute to vaccine hesitancy, but it is unknown how community-level factors affect COVID-19 booster dose hesitancy. The current study aims to fill this knowledge gap by comparing data from a nationwide survey on COVID-19 vaccine hesitancy with a community-level indicator, i.e., the Distressed Communities Index (DCI). Methods: Attitudes toward vaccinations, vaccine literacy, COVID-19 vaccine confidence index, and trust were measured using a 48-item, psychometrically valid and reliable survey tool. In this study, 2138 survey participants residing in the United States were divided into quintiles of varying community distress levels based on their zip codes using the DCI. Data were analyzed through Chi-square, one-way ANOVA, and post hoc analysis with Tukey's test. Results: A significantly higher proportion of participants from the distressed communities had lower trust than their prosperous counterparts (26.6% vs. 37.6%, p < 0.001). On the contrary, participants from the prosperous communities had significantly higher vaccine confidence index scores than those in distressed communities (2.22 ± 1.13 vs. 1.70 ± 1.01, p < 0.001). Conclusions: These findings affirm the importance of developing community-level interventions to promote trust in COVID-19 vaccinations and increase booster dose uptake. From these results, future studies can examine the efficacy of various community-level interventions.

Neighborhoods And Health: Interventions At The Neighborhood Level Could Help Advance Health Equity

Housing is tied to neighborhoods. Therefore, to understand how housing affects health and health equity, the role of neighborhood environments must be considered. This article is a critical review of the relationship between neighborhoods and health. We discuss inequality among US neighborhoods and the roots of that inequality. We then explore the ways in which neighborhood environments may shape health, review the evidence about these effects, and discuss policy responses. Many studies document an association between neighborhoods and physical and mental health, and a few studies suggest that some of these relationships are causal. Thus, the evidence suggests that interventions at the neighborhood scale can potentially help advance health equity. Further research on the long-term impacts of neighborhoods on health and more rigorous studies of the impact of particular neighborhood interventions are needed. To advance health equity, policy makers also need to better understand the institutional arrangements and social policies that have created neighborhood inequality and pursue innovative approaches to changing them.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Exposing Pittsburgh Landlords To Asset-Framing Narratives: An Experiment To Increase Housing Voucher Participation

Landlords are essential actors within the rental housing market, and there is much to be learned about their willingness to participate in rental assistance programs that improve access to stable housing. Because the success of these programs, such as the Mobility (Location-Based) Voucher program in Pittsburgh, Pennsylvania, can be derailed by landlord opposition, it is important to test strategies that increase landlords' participation. Using data from a unique survey of Pittsburgh landlords, we found that exposing landlords to an asset-framing narrative that highlighted the social, economic, and health benefits of receiving a mobility voucher increased landlords' reported willingness to rent to a mobility voucher recipient by 21 percentage points. Reported willingness was also higher among landlords who believed that housing affordability was connected to health. Our findings offer insight into how to increase landlords' participation in affordable housing programs that require their engagement to succeed.

Eviction and Poverty in American Cities

More than two million U.S. households have an eviction case filed against them each year. Policy makers at the federal, state, and local levels are increasingly pursuing policies to reduce the number of evictions, citing harm to tenants and high public expenditures related to homelessness. We study the consequences of eviction for tenants using newly linked administrative data from two major urban areas: Cook County (which includes Chicago) and New York City. We document that before housing court, tenants experience declines in earnings and employment and increases in financial distress and hospital visits. These pre trends pose a challenge for disentangling correlation and causation. To address this problem, we use an instrumental variables approach based on cases randomly assigned to judges of varying leniency. We find that an eviction order increases homelessness and hospital visits and reduces earnings, durable goods consumption, and access to credit in the first two years. Effects on housing and labor market outcomes are driven by effects for female and Black tenants. In the longer run, eviction increases indebtedness and reduces credit scores.

Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes

OBJECTIVE

To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes.

METHODS

This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions.

RESULTS

The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396).

CONCLUSION

Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups.

LEVEL OF EVIDENCE: 3

Laryngoscope, 134:954-962, 2024.

Multidimensional well-being of US households at a fine spatial scale using fused household surveys

Social science often relies on surveys of households and individuals. Dozens of such surveys are regularly administered by the U.S. government. However, they field independent, unconnected samples with specialized questions, limiting research questions to those that can be answered by a single survey. The presented data comprise the fusion onto the American Community Survey (ACS) microdata of select donor variables from the Residential Energy Consumption Survey (RECS) of 2015, the National Household Travel Survey (NHTS) of 2017, the American Housing Survey (AHS) of 2019, and the Consumer Expenditure Survey - Interview (CEI) for the years 2015-2019. This results in an integrated microdataset of household attributes and well-being dimensions that can be analyzed to address research questions in ways that are not currently possible. The underlying statistical techniques, designed under the fusionACS project, are included in an open-source R package, fusionModel, that provides generic tools for the creation, analysis, and validation of fused microdata.

Upward Mobility Context and Health Outcomes and Behaviors during Transition to Adulthood: The Intersectionality of Race and Sex

This study investigates how upward mobility context affects health during transition to adulthood and its variations by race and sex. Using county-level upward mobility measures and data from the Panel Study of Income Dynamics, we apply propensity score weighting techniques to examine these relationships. Results show that low upward mobility context increases the likelihood of poor self-rated health, obesity, and cigarette use but decreases alcohol consumption probability. Conversely, high upward mobility context raises the likelihood of distress, chronic conditions, and alcohol use but reduces cigarette use likelihood. In low-opportunity settings, Black individuals have lower risks of chronic conditions and cigarette use than White men. In high-opportunity settings, Black women are more likely to experience depression and chronic conditions, and Black men are likelier to smoke than White men. Our findings emphasize the complex link between upward mobility context and health for different racial and sex groups.

Geographical peer effect in serial mergers and acquisitions: The influence of social learning and director network

Based on the serial mergers and acquisitions(M&A) data of Chinese A-share listed companies from 2010 to 2019, this paper discusses whether there are geographical peer effects in serial M&A, and tests its mechanism and influence path. The empirical study shows that geographical peer decision-making has geographical peer effects in the decision-making of serial M&A, and the average number of serial M&A of geographical peers has a significant positive impact on the serial M&A decision-making of focal firms. Social learning and director networks are essential to produce geographical peer effects in serial M&A. The external learning mechanism shows that the geographical peer effect of serial M&A decision-making is partly caused by backward firms' social learning to the leading peer firms' decision-making, but vice versa. The director network relationship of focal firms can positively moderate the relationship between the geographical peer firms' average serial M&A decision-making and the focal firm's serial M&A decision-making. This paper reveals the mechanism of geographical peer effect in serial M&A decision-making and provides a new perspective to understand the motivation of serial M&A decision-making. These empirical findings not only provide important empirical evidence on serial M&A from developing countries such as China, but also provide a valuable reference for decision-makers and researchers of serial M&A in the future.

Human mobility networks reveal increased segregation in large cities

A long-standing expectation is that large, dense and cosmopolitan areas support socioeconomic mixing and exposure among diverse individuals1-6. Assessing this hypothesis has been difficult because previous measures of socioeconomic mixing have relied on static residential housing data rather than real-life exposures among people at work, in places of leisure and in home neighbourhoods7,8. Here we develop a measure of exposure segregation that captures the socioeconomic diversity of these everyday encounters. Using mobile phone mobility data to represent 1.6 billion real-world exposures among 9.6 million people in the United States, we measure exposure segregation across 382 metropolitan statistical areas (MSAs) and 2,829 counties. We find that exposure segregation is 67% higher in the ten largest MSAs than in small MSAs with fewer than 100,000 residents. This means that, contrary to expectations, residents of large cosmopolitan areas have less exposure to a socioeconomically diverse range of individuals. Second, we find that the increased socioeconomic segregation in large cities arises because they offer a greater choice of differentiated spaces targeted to specific socioeconomic groups. Third, we find that this segregation-increasing effect is countered when a city's hubs (such as shopping centres) are positioned to bridge diverse neighbourhoods and therefore attract people of all socioeconomic statuses. Our findings challenge a long-standing conjecture in human geography and highlight how urban design can both prevent and facilitate encounters among diverse individuals.

Strangers in a strange land: mapping household and neighbourhood associations with improved wellbeing outcomes in Accra, Ghana

Urban poverty is not limited to informal settlements, rather it extends throughout cities, with the poor and affluent often living in close proximity. Using a novel dataset derived from the full Ghanaian Census, we investigate how neighbourhood versus household socio-economic status (SES) relates to a set of household development outcomes (related to housing quality, energy, water and sanitation, and information technology) in Accra, Ghana. We then assess "stranger" households' outcomes within neighbourhoods: do poor households fare better in affluent neighbourhoods, and are affluent households negatively impacted by being in poor neighbourhoods? Through a simple generalized linear model we estimate the variance components associated with household and neighbourhood status for our outcome measures. Household SES is more closely associated with 13 of the 16 outcomes assessed compared to the neighbourhood average SES. Second, for 9 outcomes poor households in affluent areas fair better, and the affluent in poor areas are worse off. For two outcomes, poor households have worse outcomes in affluent areas, and the affluent have better outcomes in poor areas, on average. For three outcomes "stranger" households do worse in strange neighbourhoods. We discuss implications for mixed development and how to direct resources through households versus location-based targets.

Place-Based Developmental Research: Conceptual and Methodological Advances in Studying Youth Development in Context

Scientists have, for some time, recognized that development unfolds in numerous settings, including families, schools, neighborhoods, and organized and unorganized activity settings. Since the turn of the 20th century, the body of mainstream neighborhood effects scholarship draws heavily from the early 20th century Chicago School of Sociology frameworks and have been situating development in neighborhood contexts and working to identify the structures and processes via which neighborhoods matter for a range of developmental outcomes, especially achievement, behavioral and emotional problems, and sexual activity. From this body of work, two new areas of developmental scholarship are emerging. Both areas are promising for advancing an understanding of child development in context. First, cultural-developmental neighborhood researchers are advancing neighborhood effects research that explicitly recognizes the ways that racial, ethnic, cultural, and immigrant social positions matter for neighborhood environments and for youths' developmental demands, affordances, experiences, and competencies. This body of work substantially expands the range of developmental outcomes examined in neighborhood effects scholarship to recognize normative physical, emotional, cognitive, behavioral, social, and cultural competencies that have largely been overlooked in neighborhood effects scholarship that espoused a more color-blind developmental approach. Second, activity space neighborhood researchers are recognizing that residential neighborhoods have important implications for broader activity spaces-or the set of locations and settings to which youth are regularly exposed, including, for example, schools, work, organized activities, and hang-outs. They are using newer technologies and geographic frameworks to assess exposure to residential neighborhood and extra-neighborhood environments. These perspectives recognize that time (i.e., from microtime to mesotime) and place are critically bound and that exposures can be operationalized at numerous levels of the ecological system (i.e., from microsystems to macrosystems). These frameworks address important limitations of prior development in context scholarship by addressing selection and exposure. Addressing selection involves recognizing that families have some degree of choice when selecting into settings and variables that predict families' choices (e.g., income) also predict development. Considering exposure involves recognizing that different participants or residents experience different amounts of shared and nonshared exposures, resulting in both under-and over-estimation of contextual effects. Activity space scholars incorporate exposure to the residential neighborhood environments, but also to other locations and settings to which youth are regularly exposed, like schools, after-school settings, work, and hang-outs. Unfortunately, the cultural-development and activity space streams, which have both emerged from early 20th century work on neighborhood effects on development, have been advancing largely independently. Thus, the overarching aim of this monograph is to integrate scholarship on residential neighborhoods, cultural development, and activity spaces to advance a framework that can support a better understanding of development in context for diverse groups. In Chapters I and II we present the historical context of the three streams of theoretical, conceptual, and methodological research. We also advance a comprehensive cultural-developmental activity space framework for studying development in context among children, youth, and families that are ethnically, racially, and culturally heterogeneous. This framework actively recognized diversity in ethnic, racial, immigrant, and socioeconomic social positions. In Chapters III-V we advance specific features of the framework, focusing on: (1) the different levels of nested and nonnested ecological systems that can be captured and operationalized with activity space methods, (2) the different dimensions of time and exposures or experiences that can be captured and operationalized by activity space methods, and (3) the importance of settings structures and social processes for identifying underlying mechanisms of contextual effects on development. Structures are setting features related to the composition and spatial arrangement of people and institutions (e.g., socioeconomic disadvantage, ethnic/racial compositions). Social processes represent the collective social dynamics that take place in settings, like social interactions, group activities, experiences with local institutions, mechanisms of social control, or shared beliefs. In Chapter VI, we highlight a range of methodological and empirical exemplars from the United States that are informed by our comprehensive cultural-developmental activity space framework. These exemplars feature both quantitative and qualitative methods, including method mixing. These exemplars feature both quantitative and qualitative methods, including method mixing. The exemplars also highlight the application of the framework across four different samples from populations that vary in terms of race, ethnicity, gender, age, socioeconomic status (SES), geographic region, and urbanicity. They capture activity space characteristics and features in a variety of ways, in addition to incorporating family shared and nonshared activity space exposures. Finally, in Chapter VII we summarize the contributions of the framework for advancing a more comprehensive science of development in context, one that better realizes major developmental theories emphasizing persons, processes, contexts, and time. Additionally, we offer a place-based, culturally informed developmental research agenda to meet the needs of an increasingly diverse population.

Cost-Effectiveness a Parenting Skills Program Implemented in Public PreK Schools in Disadvantaged Urban Communities

BACKGROUND

Little is known about the cost-effectiveness of parent training programs when offered universally in U.S. elementary schools in disadvantaged urban communities.

OBJECTIVE

To estimate the cost-effectiveness of a universal school-based implementation study of the Chicago Parent Program (CPP).

METHODS

CPP was offered universally from 2014 to 2017 to parents of PreK students in 12 Baltimore City Title 1 schools (n = 380; 61.1% Black/African American, 24.1% Hispanic). CPP program implementation and operating costs were estimated using microcosting methods and data drawn from study records. A Complier Average Causal Effects (CACE) framework was used to estimate an Incremental Cost Effectiveness Ratio (ICER) for CPP's average cost per child per 1% decrease in conduct problem prevalence at follow-up. This ICER was then compared with comparable ICERs for four parenting interventions that have been implemented and evaluated in Europe: Connect, Incredible Years, COPE, and Comet.

RESULTS

CPP cost $937.51 per child (95% CI: $902.09 to $971.92). Adjusted CACE estimates indicated that CPP resulted in a 31.4% reduction (95% CI: -39.7% to -23.9%) in conduct problem prevalence at follow-up among children whose parents attended CPP. The mean ICER for CPP was $29.86 per each 1% reduction in prevalence (95% CI: $21.05 to $50.71). CPP's ICER was similar to ICERs for Connect ($25.50) and COPE ($29.72), and less than ICERs for Incredible Years ($50.36) and Comet ($59.69).

CONCLUSION

School-based CPP offered universally to parents of children transitioning to Kindergarten in extremely disadvantaged U.S. urban communities was found to offer relatively good value compared with similar parenting programs that are widely used in Europe.

Social inequities impact infant mortality due to congenital heart disease

OBJECTIVES

To evaluate how educational, economic, and racial residential segregation may impact congenital heart disease infant mortality (CHD-IM).

STUDY DESIGN

This is a population-based US ecological study.

METHODS

This study evaluated linked live birth-infant death files from the National Center for Health Statistics for live births from 2006 to 2018 with cause of death attributed to CHD. Maternal race and education data were obtained from the live birth-infant death files, and income data were obtained from the American Community Survey. A spatial social polarization measure termed the Index of Concentration at the Extremes (ICE) was calculated and split by quintiles for maternal education, household income, and race for all US counties (n = 3142). The lowest quintile represents counties with highest concentration of disadvantaged groups (income < $25K, non-Hispanic Black, no high school degree). Proximity to a pediatric cardiac center (PCC) was also analyzed in a categorical manner based on whether each county was in a metropolitan area with a US News and World Report top 50 ranked PCC, a lower ranked PCC, or not proximal to any PCC.

RESULTS

Between 2006 and 2018, 17,489 infant deaths were due to CHD, an unadjusted CHD-IM of 0.33 deaths per 1000 live births. The risk of CHD-IM was 1.5 times greater among those in the lowest ICE-education quintile (0.41 [0.39-0.44] vs 0.28 deaths/1000 live births [0.27-0.29], P < 0.0001) and the lowest ICE-income quintile (0.44 [0.41-0.47] vs 0.29 [0.28-0.30], P < 0.0001) in comparison to those in the highest quintiles. CHD-IM increases with higher ICE-race value (counties with a higher concentration of non-Hispanic White mothers). However, after adjusting for proximity to a US News and World Report top 50 ranked PCC in the multivariable models, CHD-IM decreases with higher ICE-race value.

CONCLUSIONS

Counties with the highest concentration of lower-educated mothers and the highest concentration of low-income households were associated with higher rates of CHD-IM. Mortality as a function of race is more complicated and requires further investigation.

It Is Surprisingly Difficult to Measure Income Segregation

Recent studies have shown that U.S. Census- and American Community Survey (ACS)-based estimates of income segregation are subject to upward finite sampling bias (Logan et al. 2018; Logan et al. 2020; Reardon et al. 2018). We identify two additional sources of bias that are larger and opposite in sign to finite sampling bias: measurement error-induced attenuation bias and temporal pooling bias. The combination of these three sources of bias make it unclear how income segregation has trended. We formalize the three types of bias, providing a method to correct them simultaneously using public data from the decennial census and ACS from 1990 to 2015-2019. We use these methods to produce bias-corrected estimates of income segregation in the United States from 1990 to 2019. We find that (1) segregation is on the order of 50% greater than previously believed; (2) the increase from 2000 to the 2005-2009 period was much greater than indicated by previous estimates; and (3) segregation has declined since 2005-2009. Correcting these biases requires good estimates of the reliability of self-reported income and of the year-to-year volatility in neighborhood mean incomes.

Family, Community, and the Rural Social Mobility Advantage

Children born into poverty in rural America achieve higher average income levels as adults than their urban peers. As economic opportunity tends to be more abundant in cities, this "rural advantage" in income mobility seems paradoxical. This article resolves this puzzle by applying multilevel analysis to new spatial measures of rurality and place-level data on intergenerational income mobility. We show that the high level of rural income mobility is principally driven by boys of rural-origin, who are more likely than their urban peers to grow up in communities with a predominance of two-parent households. The rural advantage is most pronounced among Whites and Hispanics, as well as those who were raised in the middle of the country. However, these dynamics are more nuanced for girls. In fact, girls from lower-income rural households exhibit a disadvantage in their personal income attainment, partly due to the persistence of traditional gender norms. These findings underscore the importance of communities with strong household and community supports in facilitating later-life income mobility, particularly for boys. They also challenge the emerging consensus that attributes the rural income mobility advantage to migration from poorer rural areas to wealthier towns and cities.

Role of School Quality and Neighborhood Disadvantage in Educational Attainment: Do They Vary by Race?

Schools and neighborhoods are adolescents' primary environments, and each has a significant influence on their academic success. The majority of studies on educational attainment have examined the impact of a single context-either the school or the neighborhood-suggesting mixed findings on school and neighborhood effects as well as potential disparities across racial groups. To address this gap, the present study examined the roles of school quality and neighborhood disadvantage on educational attainment for White and Black adolescents. This study used the National Longitudinal Study of Adolescent to Adult Health data collected from a nationally representative sample of U.S. adolescents, merging multiple data sources including in-home surveys, school administrator surveys, student-level educational records, and contextual data. Educational attainment was measured using college enrollment and graduation status. School quality was a significant predictor of college enrollment and graduation for both White and Black adolescents. Neighborhood disadvantage is significantly associated with college enrollment for both racial groups; however, college graduation is significant only for White adolescents. These findings suggest that improving school quality is particularly important for educational attainment regardless of racial background. The article concludes with a discussion on the differential roles of school quality and neighborhood disadvantage in relation to White and Black adolescents.

Association Between Neighborhood Deprivation and Child Cognition in Clinically Referred Youth

OBJECTIVE

When socioeconomic status is measured at the individual and/or family level, it has long been associated with cognition in children. However, the association between neighborhood deprivation, an index of community-level socioeconomic status, and child cognition is not fully understood. The goal of this study was to investigate (1) the relationship between neighborhood deprivation and child cognitive functioning and (2) whether child age moderates the relationship between cognitive functioning and neighborhood deprivation.

METHODS

This study included 9878 children, ages 3 through 17 years (M = 10.4 yrs, SD = 3.4 yrs). Data were gathered from children referred for and evaluated at an urban, outpatient neuropsychology assessment clinic between 2006 and 2022, located in the Mid-Atlantic region of the United States. Neighborhood socioeconomic status was measured at the census block level using the Area Deprivation Index composite.

RESULTS

There was a 20-point median difference in overall intelligence between the neighborhoods with the lowest and highest levels of deprivation. Overall intelligence and verbal comprehension, compared with working memory, fluid reasoning, and processing speed, demonstrated the strongest negative association with neighborhood deprivation (all p < 0.05). Older children had lower overall intelligence scores compared with younger children in neighborhoods with high levels of deprivation ( p < 0.01), suggesting a cumulative influence of poverty exposure.

CONCLUSION

This study demonstrates the stark disparities in child cognitive functioning across levels of neighborhood deprivation. Findings support the importance of access to early interventions and services that promote intellectual growth and verbal capacity among children who live in neighborhoods with great deprivation.

Causal complexity in human research: On the shared challenges of behavior genetics, medical genetics, and environmentally oriented social science

We received 23 spirited commentaries on our target article from across the disciplines of philosophy, economics, evolutionary genetics, molecular biology, criminology, epidemiology, and law. We organize our reply around three overarching questions: (1) What is a cause? (2) How are randomized controlled trials (RCTs) and within-family genome-wide association studies (GWASs) alike and unalike? (3) Is behavior genetics a qualitatively different enterprise? Throughout our discussion of these questions, we advocate for the idea that behavior genetics shares many of the same pitfalls and promises as environmentally oriented research, medical genetics, and other arenas of the social and behavioral sciences.

Association between the Environmental Quality Index and Textbook Outcomes Among Medicare Beneficiaries Undergoing Surgery for Early-Stage Pancreatic Adenocarcinoma

BACKGROUND

Access to high-quality cancer care is affected by environmental exposures and structural inequities. This study sought to investigate the association between the environmental quality index (EQI) and achievement of textbook outcomes (TO) among Medicare beneficiaries over the age of 65 who underwent surgical resection for early-stage pancreatic adenocarcinoma (PDAC).

METHODS

Patients diagnosed with early-stage PDAC from 2004 to 2015 were identified using the SEER-Medicare database and combined with the US Environmental Protection Agency's EQI data. High EQI category indicated poor environmental quality, whereas low EQI indicated better environmental conditions.

RESULTS

A total of 5,310 patients were included, of which 45.0% (n = 2,387) patients achieved TO. Median age was 73 years and more than half were female (n = 2,807, 52.9%), married (n = 3,280, 61.8%), and resided in the Western region of the US (n = 2,712, 51.1%). On multivariable analysis, patients residing in moderate and high EQI counties were less likely to achieve a TO (referent: low EQI; moderate EQI: OR 0.66, 95% CI 0.46-0.95; high EQI: OR 0.65, 95% CI 0.45-0.94; p < 0.05). Increasing age (OR 0.98, 95%CI 0.97-0.99), racial minorities (OR 0.73, 95% CI 0.63-0.85), having a Charlson co-morbidity index > 2 (OR 0.54, 95%CI 0.47-0.61) and stage II disease (OR 0.82, 95%CI 0.71-0.96) were also associated with not achieving a TO (all p < 0.001).

CONCLUSION

Older Medicare patients residing in moderate or high EQI counties were less likely to achieve an "optimal" TO after surgery. These results demonstrate that environmental factors may drive post-operative outcomes among patients with PDAC.

Neighborhood context and children's health care utilization and health outcomes: a comprehensive descriptive analysis of national survey data

While child health and health care disparities arising from unequal distribution of resources are well documented, a nationally representative inventory of health and well-being for children across the spectrum of opportunity is lacking. Using the nationally representative sample of children from pooled 2013-2017 Medical Expenditure Panel Survey data linked to the census-tract-level Child Opportunity Index 2.0, a composite measure of neighborhood health, education, and socioeconomic conditions, we describe US children's socioeconomic characteristics, health care utilization and expenditures across the spectrum of child neighborhood opportunity levels. We found that neighborhood level of child opportunity was associated with almost all of children's health status, health care utilization, expenditures, access to care, and satisfaction with care outcomes. Children living in lower-opportunity neighborhoods had the highest rates of poor physical and mental health status and fewest ambulatory care visits but accounted for the highest share of emergency department visits. Their parents were also least likely to report having positive experiences with health care, good communication with providers, and easy access to care. Our findings underscore the myriad harms to children of gaps in health, education, and financial resources at the community level and provide targets for public investments to improve child-focused outcomes.

Identifying groups of children's social mobility opportunity for public health applications using k-means clustering

Background

The Opportunity Atlas project is a pioneering effort to trace social mobility and adulthood socioeconomic outcomes back to childhood residence. Half of the variation in adulthood socioeconomic outcomes was explainable by neighborhood-level socioeconomic characteristics during childhood. Clustering census tracts by Opportunity Atlas characteristics would allow for further exploration of variance in social mobility. Our objectives here are to identify and describe spatial clustering trends within Opportunity Atlas outcomes.

Methods

We utilized a k-means clustering machine learning approach with four outcome variables (individual income, incarceration rate, employment, and percent of residents living in a neighborhood with low levels of poverty) each given at five parental income levels (1st, 25th, 50th, 75th, and 100th percentiles of the national distribution) to create clusters of census tracts across the contiguous United States (US) and within each Environmental Protection Agency region.

Results

At the national level, the algorithm identified seven distinct clusters; the highest opportunity clusters occurred in the Northern Midwest and Northeast, and the lowest opportunity clusters occurred in rural areas of the Southwest and Southeast. For regional analyses, we identified between five to nine clusters within each region. PCA loadings fluctuate across parental income levels; income and low poverty neighborhood residence explain a substantial amount of variance across all variables, but there are differences in contributions across parental income levels for many components.

Conclusions

Using data from the Opportunity Atlas, we have taken four social mobility opportunity outcome variables each stratified at five parental income levels and created nationwide and EPA region-specific clusters that group together census tracts with similar opportunity profiles. The development of clusters that can serve as a combined index of social mobility opportunity is an important contribution of this work, and this in turn can be employed in future investigations of factors associated with children's social mobility.

Schools' Neighborhoods and Characteristics: Implications for Standardized Academic Achievement in Passaic, NJ's Elementary, Middle and High Schools

Schools in urban neighborhoods receive less funding, have less programming, and have poorer infrastructure. Such disparities may impede academic outcomes among youth. This study used publicly available data to examine the association between school characteristics and surrounding neighborhood environment on educational outcomes across three academic years among 132 schools in Passaic County, New Jersey. Further, we assessed how schools' socioeconomic status could buffer the effects of a school's neighborhood disadvantage on academic outcomes. Results supported compound deprivation theory highlighting that lower-performing schools were located in lower-resourced neighborhoods. Further, school characteristics and neighborhood resource deprivation were associated with lower math, English, and science academic performance. Additionally, we found that associations between neighborhood resources and math and science academic outcomes were strongest in schools with greater economic support. We provide implications for research and practice by identifying multi-faceted approaches to challenge educational disparities addressing school and neighborhood-level disadvantages to improve educational outcomes for youth.

The psychology and policy of overcoming economic inequality

Recent arguments claim that behavioral science has focused - to its detriment - on the individual over the system when construing behavioral interventions. In this commentary, we argue that tackling economic inequality using both framings in tandem is invaluable. By studying individuals who have overcome inequality, "positive deviants," and the system limitations they navigate, we offer potentially greater policy solutions.

Characteristics and neighborhood-level opportunity of assault-injured children in Milwaukee

BACKGROUND

Multiple studies have explored demographic characteristics and social determinants of health in relation to the risk of pediatric assault-related injuries and reinjury. However, few have explored protective factors. The Child Opportunity Index (COI) uses neighborhood-level indicators to measure 'opportunity' based on factors such as education, social environment, and economic resources. We hypothesized that higher 'opportunity' would be associated with less risk of reinjury in assault-injured youth.

METHODS

This was a single-institution, retrospective study at a Level 1 Pediatric Trauma Center. Trauma registry and electronic medical record data were queried for children ≤ 18 years old with assault-related injuries from 1/1/2016 to 5/31/2021. Reinjured children, defined as any child who sustained more than one assault injury, were compared to non-reinjured children. Area Deprivation Index (ADI), a marker of socioeconomic status, and COI were determined through census block and tract data, respectively. A post-hoc analysis examined COI between all assault-injured children, unintentionally injured children, and a state-based normative cohort representative of non-injured children.

RESULTS

There were 55,862 traumatic injury encounters during the study period. Of those, 1224 (2.3%) assault injured children were identified, with 52 (4.2%) reinjured children and 1172 (95.8%) non-reinjured children. Reinjured children were significantly more likely to be older (median age 15.0 [IQR 13.8-17.0] vs. median age 14.0 [IQR 8.8-16.0], p < 0.001) and female (55.8% vs. 37.5%, p = 0.01) than non-reinjured children. COI was not associated with reinjury. There were also no significant differences in race, ethnicity, insurance status, ADI, or mechanism and severity of injury between cohorts. Post-hoc analysis revealed that assault-injured children were more likely to live in areas of lower COI than the other cohorts.

CONCLUSIONS

Compared to children who sustained only one assault during the study period, children who experienced more than one assault were more likely to be older and female. Furthermore, living in an area with more or less opportunity did not influence the risk of reinjury. However, all assault-injured children were more likely to live in areas of lower COI compared to unintentionally injured and a state-based normative cohort. Identification of factors on a social or environmental level that leads to assaultive injury warrants further exploration.

Race, Poverty, and Foster Care Placement in the United States: Longitudinal and Cross-Sectional Perspectives

Although the connections between race, poverty, and foster care placement seem obvious, the link has not in fact been studied extensively. To address this gap, we view poverty and placement through longitudinal and cross-sectional lenses to more accurately capture how changes in poverty rates relate to changes in placement frequency. The longitudinal study examines the relationship between poverty rate changes and changes in the placement of Black and White children between 2000 and 2015. The cross-sectional study extends the longitudinal analysis by using a richer measure of socio-ecological diversity and more recent foster care data. Using Poisson regression models, we assess the extent to which changes in race-differentiated child poverty rates are correlated with Black and White child placement frequencies and placement disparities. Regardless of whether one looks longitudinally or cross-sectionally, we find that Black children are placed in foster care more often than White children. Higher White child poverty rates are associated with substantially reduced placement differences; however, higher Black child poverty rates are associated with relatively small changes in placement disparity. Black and White child placement rates are more similar in counties with the fewest socio-ecological assets.

Alternative Payment Models and Working with Payers-Key Considerations for Advancing Population Health Goals and Achieving Child Health Equity

This article summarizes approaches to achieving value-based care in Pediatrics, providing a framework for understanding the continuum of models from fee-for-service to advanced alternative payment models. We present key examples of how alternative payment models have been developed and applied at the federal level within Medicare through the work of the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicaid and Medicaid Innovation (CMMI). We further describe key lessons learned and opportunities to adapt value-based payment models to promote whole child health and equity. Finally, we summarize policy considerations and challenges in achieving accountability and aligning financial incentives for children's health within a complex payer landscape.

The Impact of Increased Minimum Wage on Child Neglect Varies by Developmental Age of Child

Children in poverty are at significantly greater risk of experiencing child maltreatment. Family economic security policies, such as minimum wage laws, offer a promising prevention strategy to support low-income families. This study utilized data from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort study, to examine the effect of changes in state-specific minimum wage laws on maternal self-reported child maltreatment and material hardship as it varies by developmental age of the child. A series of fixed effects models with an interaction between the minimum wage and the age of the focal child were used to estimate if there was variation by developmental period of the impact of minimum wage laws on the following outcome variables: all domains of child maltreatment, maternal work-related stress, reported material hardship, aggravation in parenting, and maternal depression. Results revealed significant effects of increased minimum wage on maternal self-reported child neglect and material hardship when children are 3 years of age, and this relationship became non-significant as children aged. No effect was observed by age for other forms of child maltreatment nor any other outcome variables. Study findings suggest minimum wage laws may have differential effects on child neglect depending on the developmental period in which they are received.

What Difference Does a Health Plan Make? Evidence from Random Plan Assignment in Medicaid

Exploiting the random assignment of Medicaid beneficiaries to managed care plans, we find substantial plan-specific spending effects despite plans having identical cost sharing. Enrollment in the lowest-spending plan reduces spending by at least 25%-primarily through quantity reductions-relative to enrollment in the highest-spending plan. Rather than reducing "wasteful" spending, lower-spending plans broadly reduce medical service provision-including the provision of low-cost, high-value care-and worsen beneficiary satisfaction and health. Consumer demand follows spending: a 10 percent increase in plan-specific spending is associated with a 40 percent increase in market share. These facts have implications for the government's contracting problem and program cost growth.

Mental health and labor supply: Evidence from Canada

This study investigates the relationship between mental health and employment using an instrumental variable approach with the 2012 Canadian Community Health Survey-Mental Health. Using a family member's mental health problem(s) as an instrument for poor mental health, the estimates reveal that poor mental health significantly reduces employment outcomes. These findings are robust to various specifications, such as an alternative instrument and a relaxation of the exclusion restriction assumption. In addition, the relationship is driven mainly by men and younger workers. Moreover, the findings suggest that the relationship is mediated by a decline in cognitive abilities, such as difficulties in concentration and motivation, and social relations with acquaintances and friends. Finally, the estimates show that this phenomenon is contagious: poor mental health has a significant spillover effect on coworkers' mental health in workplaces. This study demonstrates the importance of mental health illness in Canada and other developed countries.

Understanding Heterogeneity in the Impact of Public Preschool Programs

We examine the North Carolina Pre-K (NC Pre-K) program to test the hypothesis that observed variation in effects resulting from exposure to the program can be attributed to interactions with other environmental factors that occur before, during, or after the pre-k year. We examine student outcomes in 5th grade and test interaction effects between NC's level of investment in public pre-k and moderating factors. Our main sample includes the population of children born in North Carolina between 1987 and 2005 who later attended a public school in that state, had valid achievement data in 5th grade, and could be matched by administrative record review (n = 1,207,576; 58% White non-Hispanic, 29% Black non-Hispanic, 7% Hispanic, 6% multiracial and Other race/ethnicity). Analyses were based on a natural experiment leveraging variation in county-level funding for NC Pre-K across NC counties during each of the years the state scaled up the program. Exposure to NC Pre-K funding was defined as the per-4-year-old-child state allocation of funds to a county in a year. Regression models included child-level and county-level covariates and county and year fixed effects. Estimates indicate that a child's exposure to higher NC Pre-K funding was positively associated with that child's academic achievement 6 years later. We found no effect on special education placement or grade retention. NC Pre-K funding effects on achievement were positive for all subgroups tested, and statistically significant for most. However, they were larger for children exposed to more disadvantaged environments either before or after the pre-k experience, consistent with a compensatory model where pre-k provides a buffer against the adverse effects of prior negative environmental experiences and protection against the effects of future adverse experiences. In addition, the effect of NC Pre-K funding on achievement remained positive across most environments, supporting an additive effects model. In contrast, few findings supported a dynamic complementarity model. Instrumental variables analyses incorporating a child's NC Pre-K enrollment status indicate that program attendance increased average 5th grade achievement by approximately 20% of a standard deviation, and impacts were largest for children who were Hispanic or whose mothers had less than a high school education. Implications for the future of pre-k scale-up and developmental theory are discussed.

Early childhood household instability, adolescent structural neural network architecture, and young adulthood depression: A 21-year longitudinal study

Unstable and unpredictable environments are linked to risk for psychopathology, but the underlying neural mechanisms that explain how instability relate to subsequent mental health concerns remain unclear. In particular, few studies have focused on the association between instability and white matter structures despite white matter playing a crucial role for neural development. In a longitudinal sample recruited from a population-based study (N = 237), household instability (residential moves, changes in household composition, caregiver transitions in the first 5 years) was examined in association with adolescent structural network organization (network integration, segregation, and robustness of white matter connectomes; Mage = 15.87) and young adulthood anxiety and depression (six years later). Results indicate that greater instability related to greater global network efficiency, and this association remained after accounting for other types of adversity (e.g., harsh parenting, neglect, food insecurity). Moreover, instability predicted increased depressive symptoms via increased network efficiency even after controlling for previous levels of symptoms. Exploratory analyses showed that structural connectivity involving the left fronto-lateral and temporal regions were most strongly related to instability. Findings suggest that structural network efficiency relating to household instability may be a neural mechanism of risk for later depression and highlight the ways in which instability modulates neural development.

How does the local area deprivation influence life chances for children in poverty in Wales: A record linkage cohort study

Objectives

Children growing up in poverty are less likely to achieve in school and more likely to experience mental health problems. This study examined factors in the local area that can help a child overcome the negative impact of poverty.

Design

A longitudinal record linkage retrospective cohort study.

Participants

This study included 159,131 children who lived in Wales and completed their age 16 exams (Key Stage 4 (KS4)) between 2009 and 2016. Free School Meal (FSM) provision was used as an indicator of household-level deprivation. Area-level deprivation was measured using the Welsh Index of Multiple Deprivation (WIMD) 2011. An encrypted unique Anonymous Linking Field was used to link the children with their health- and educational records.

Outcome measures

The outcome variable 'Profile to Leave Poverty' (PLP) was constructed based on successful completion of age 16 exams, no mental health condition, no substance and alcohol misuse records in routine data. Logistic regression with stepwise model selection was used to investigate the association between local area deprivation and the outcome variable.

Results

22% of children on FSM achieved PLP compared to 54.9% of non-FSM children. FSM Children from least deprived areas were significantly more likely to achieve PLP (adjusted odds ratio (aOR) - 2.20 (1.93, 2.51)) than FSM children from most deprived areas. FSM children, living in areas with higher community safety, higher relative income, higher access to services, were more likely to achieve PLP than their peers.

Conclusion

The findings indicate that community-level improvements such as increasing safety, connectivity and employment might help in child's education attainment, mental health and reduce risk taking behaviours.

Cumulative Neurotoxicological Air Pollution Exposure Is Associated with Lower Reading Improvement and Diminished Benefits of Literacy Interventions for Urban Elementary Students of Color

The cognitive and behavioral deficits associated with air pollution exposure may have far-reaching negative effects on children's scholastic achievement. Moreover, air pollution may be conditioning the success of educational investments that support students who face greatest levels of societal adversity. This study examined the direct main effects of cumulative neurotoxicological exposure on annual reading improvement. We also tested the statistical interaction (i.e., moderation) of neurotoxicological exposure and academic intervention sessions on annual reading improvement for a large sample of ethnic minority (95%) elementary school children (n = 6080, k-6th grade) enrolled in a standard literacy enrichment program. These children were all behind grade level in reading and attended predominantly low-income schools (n = 85) in urban settings across the state of California. Multi-level modeling assessments accounted for random effects associated with school and neighborhood environments, and incorporated extensive individual, school, and community level covariates. Findings show individual elementary students of color to progress less in reading when exposed to greater accumulations of neurotoxin air pollution in their home and school environments, with the average deficit equivalent to 1.5 weeks of learning delay per year. Findings also show neurotoxicological exposure to diminish the efficacy of literacy intervention sessions received on reading improvement throughout the school year. Results suggest that pollution abatement can be a salient strategy to help bridge the child educational achievement gap. In addition to several methodological strengths, this study is one of the first to show that ambient pollution can undermine program efficacy of a literacy enrichment program.