Toward A Policy-Relevant Analysis Of Geographic And Racial/Ethnic Disparities In Child Health

Associations between gestational exposure to neighbourhood socioeconomic deprivation and early childhood weight status

OBJECTIVE

This study aimed to examine associations between prenatal neighbourhood socioeconomic deprivation (NSD) with early offspring weight status and to assess potential modification by race and ethnicity.

METHODS

We used data from the Newborn Epigenetics STudy (NEST) cohort. Gestational NSD was assessed as neighbourhood deprivation index (NDI) tertiles. Offspring height and weight were assessed at 6 months (N = 1023), 1 year (N = 1268), 2 years (N = 1033) and 3 years (N = 1038). Multilevel logistic regression models estimated odds ratios (OR) and 95% confidence intervals (CI) for the relationship of NDI with overweight or obesity and rapid infant weight gain, adjusting for gestational parent age, race/ethnicity, marital status and educational attainment. Models were estimated in the total sample and also stratified by race and ethnicity.

RESULTS

Children exposed to NDI in the highest (compared to the lowest) tertile had increased odds of having overweight/obesity at 1 year (OR = 1.53, 95%CI = 1.09-2.15). In stratified models, children of NH Black gestational parents residing in the highest tertile of NDI (compared to the lowest) had increased odds of having overweight/obesity at 1 year (OR = 1.67, 95%CI = 1.00-2.77).

CONCLUSIONS

This findings suggest that higher gestational exposure to NSD may play a role in early childhood weight status, which has important implications for later development and health.

Neighborhood socioeconomic disadvantage and child health: The role of neighborhood mobility networks

Despite a large body of work on neighborhood effects on health, past studies are limited in their treatment of neighborhoods as largely static spaces with (dis)advantages based primarily on the average characteristics of their residents. In this study, we draw on the triple neighborhood disadvantage perspective to explore how socioeconomic disadvantage in a neighborhood's mobility network uniquely relates to children's overall health levels, independent of residential disadvantage. We investigate this by combining 2019 SafeGraph data on mobility patterns from roughly 40 million U.S. mobile devices with information on children, families, and neighborhoods from the 2015-19 American Community Survey and 2019 Panel Study of Income Dynamics Child Development supplement. We find that mobility-based neighborhood disadvantage (MND) generally predicts child health better than residential neighborhood disadvantage (RND), but associations vary by race and by family income and are contingent on the broader metropolitan context. Our study advances existing research on the effects of mobility networks by shifting from analyzing aggregate-level outcomes to exploring how mobility-based disadvantage affects individual outcomes. Overall, our results indicate that the relationship between neighborhood disadvantage and child health is nuanced and complex. Findings from our study suggest that researchers aiming to understand the influence of neighborhood contexts should examine individuals' residential environments as well as the environments of neighborhoods connected through individuals' everyday mobility.

A child opportunity index in Italy: a pilot proposal

BACKGROUND

The Child Opportunity Index (COI) is a new and innovative tool designed to assess the environment in which children grow up, offering a broad evaluation of the opportunities available to them in different neighborhoods. This initiative aims to ensure improvements in children's living conditions and future health outcomes.

METHODS

The study was performed in the cities of Palermo and Rome. Our Italian COI consists of three main domains: education, health and environment, and economy, each subdivided into specific indicators. We collected information, when available, useful for our indicators from institutional sites and municipal archives. Furthermore, in the city of Rome, we distributed a questionnaire through local pediatricians, collecting data in 2 randomly chosen neighborhoods with questions on children's health and quality of life, proposing an initial approach that, when implemented using data provided by the government and public and private health institutions, aims to evaluate the correlation between socio-economic opportunities and the psycho-physical health of children, as demonstrated in the literature.

RESULTS

As a result, many aspects, such as the rate of air pollution or the illegal occupation of houses, were not taken into consideration. We therefore consider our COI proposal only a starting model that will have to be implemented once all the necessary information has been obtained. However, what can be deduced from this first descriptive study is how the opportunities in different neighborhoods are not the same for all children. The number of educational opportunities as well as the number of environmental opportunities differs between the various districts and is not homogeneous between different cities or within the same city.

CONCLUSIONS

In conclusion, it is not simple to analyze in a scientific manner the child's health impact of living in different areas. The COI could be a useful and simple tool that can give us this information. Pediatricians could collaborate with institutions to implement intervention plans and to reduce existing differences, social and health inequalities. Future studies will have to implement this pilot study to create and validate an Italian model of COI to be used as a useful tool in children's assistance.

Allostatic Load as a Mediator and Perceived Chronic Stress as a Moderator in the Association between Maternal Mental Health and Preterm Birth: A Prospective Cohort Study of Pregnant Women in Pakistan

INTRODUCTION

The complex biopsychosocial pathways linking maternal mental health with preterm birth (PTB) are not well understood. This study aimed to explore allostatic load (AL) as a mediator and perceived chronic stress as a moderator in the pathway linking maternal mental health and PTB.

METHODS

A cohort study of pregnant women (n = 1,567) recruited at clinic visits within 10-19 weeks of gestation was assessed for maternal mental health (i.e., pregnancy-related anxiety, state anxiety, depressive symptoms) and perceived chronic stress. Blood pressure and levels of cortisol, total cholesterol, C-reactive protein, and glycosylated hemoglobin were used to create a composite measure of AL.

RESULTS

AL had the most significant effect on PTB (odds ratio (OR) = 1.84, 95% CI = 1.26-12.67, p = 0.001), while systolic blood pressure emerged as the only significant individual marker using variable selection (OR = 22%, 95% CI = 1.06-1.40, p < 0.001) in multiple logistic regression analysis. A mediation analysis revealed that maternal mental health did not have a significant direct effect on PTB (p = 0.824), but its indirect effect mediated by AL was significant (z = 2.33, p < 0.020). Low and high levels of perceived chronic stress, relative to the mean, moderated this indirect effect (z = 3.66, p < 0.001).

CONCLUSIONS

AL has a significant direct influence on PTB and mediates the effect of maternal mental health on PTB; however, the indirect effect of AL is indistinguishable between women with higher or lower levels of perceived chronic stress than normal.

Poverty reduction and childhood opportunity moves: A randomized trial of cash transfers to low-income U.S. families with infants

Black and Hispanic children have a higher likelihood of experiencing neighborhood poverty than white children. This study uses data from the Baby's First Years (BFY) randomized trial to examine whether an unconditional cash transfer causes families to make opportunity moves to better quality neighborhoods. We use Intent to Treat linear regression models to test whether the BFY treatment, of receiving $333/month (vs. $20/month) for three years, leads to moves to neighborhoods of greater childhood opportunity. Overall, we find no relation between the BFY treatment and neighborhood opportunity across time. However, we find effect modification by maternal baseline health. High-cash receipt among mothers with poor health at baseline corresponds with moves to neighborhoods of greater childhood opportunity.

Higher substance use is associated with low executive control neural activity and higher inflammation

Individuals with substance use problems show lower executive control and alterations in prefrontal brain systems supporting emotion regulation and impulse control. A separate literature suggests that heightened inflammation also increases risk for substance use, in part, through targeting brain systems involved in executive control. Research on neural and inflammatory signaling in substance use, however, has occurred in parallel. Drawing on recent neuroimmune network models, we used fMRI to examine the relationships between executive control-related brain activity (as elicited by an n-back working memory task), peripheral inflammation, as quantified by inflammatory cytokines and C-reactive protein (CRP), and substance use for the past month in 93 participants [mean age = 24.4 (SD = 0.6)]. We operationalized low executive control as a neural inefficiency during the n-back task to achieve normative performance, as reflected in higher working memory-related brain activity and lower activity in the default mode network (DMN). Consistent with prediction, individuals with low executive control and high inflammation reported more substance use over the past month, controlling for behavioral performance on the n-back, sex, time between assessments, body-mass-index (BMI), and personal socioeconomic status (SES) (interaction between inflammation and working memory-related brain activity, b = 0.210, p = 0.005; interaction between inflammation and DMN, b = -0.219, p < 0.001). Findings suggest that low executive control and high inflammation may be associated with higher substance use. This has implications for understanding psychological, neural, and immunological risk for substance use problems and the development of interventions to target each of these components.

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.

Does poor health influence residential selection? Understanding mobility among low-income housing voucher recipients in the Moving to Opportunity Study

Housing mobility programs and housing choice vouchers provide low-income families with a potentially-transformative opportunity to move to low-poverty neighborhoods. However, families often face barriers to attaining upward residential mobility; poor health may be one important barrier, although few studies have examined this hypothesis. We used the experimental Moving to Opportunity (MTO) Study, constructed residential trajectories, and linked neighborhood opportunity measures to over 14,000 addresses of 3526 families across 7 years. We used latent growth curve longitudinal models to test how baseline health modified effects of MTO housing voucher treatment on neighborhood opportunity trajectories. Results show that poor baseline health adversely influenced how the voucher induced upward mobility. Voucher receipt strongly promoted residential mobility if families were healthy; moreover the low-poverty neighborhood voucher plus counseling treatment promoted higher opportunity neighborhood attainment compared to controls, regardless of the baseline health of the family. However families with health vulnerabilities did not retain the same initial neighborhood gains conferred by the housing choice voucher treatment, as families without health vulnerabilities. These results suggest that housing counseling may be one necessary element to expand neighborhood choice into higher opportunity neighborhoods for families with health challenges. Providing housing vouchers alone are insufficient to promote low-income family high opportunity moves, for families who have disabilities or special needs. The implications of these results point to scaling up housing mobility programs, to provide tailored support for low-income families to use housing choice vouchers to make high opportunity moves, which is particularly necessary for families with health challenges.

Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children

OBJECTIVE

To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously.

DATA SOURCES

We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation.

STUDY DESIGN

We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state.

DATA EXTRACTION METHODS

We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions.

PRINCIPAL FINDINGS

Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations.

CONCLUSIONS

Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.

Connecting the Dots between Barriers to W.I.C. Access and Adult and Child Food Insecurity: A Survey of Missouri Residents

Background. Previous research has explored the impact of W.I.C. on recipients' health, but less is known about the connection between barriers to W.I.C. access and health outcomes. We fill in a gap in the literature by studying the relationship between barriers to Special Supplemental Nutrition Program for Women, Infants, and Children (W.I.C.) access and adult and child food insecurity. Methods. After survey administration, we analyzed a cross-sectional sample of 2244 residents in Missouri who have used W.I.C. or lived in a household with a W.I.C. recipient in the past three years. We ran logistic regression models to understand the relationships among barriers to W.I.C. utilization, adult food insecurity, and child food insecurity. Results. Having special dietary needs (for adults), lacking access to technology, encountering inconvenient clinic hours of operation, and experiencing difficulties taking off work were associated with increased adult food insecurity. Difficulties finding WIC-approved items in the store, technological barriers, inconvenient clinic hours, difficulties taking off work, and finding childcare were associated with increased child food insecurity. Conclusion. Barriers to accessing and utilizing W.I.C. are associated with adult and child food insecurity. However, current policies suggest promising approaches to curbing these barriers.

Neighborhood deprivation, built environment, and overweight in adolescents in the city of Oslo

BACKGROUND

Even though the social and built environment characteristics of neighborhoods have been studied as potential determinants of social inequalities in obesity among adults, fewer studies have focused on children. Our first aim was to investigate whether there were differences in the food and physical activity environments between different neighborhood deprivation levels in the city of Oslo. We also explored whether there was an association between the prevalence of overweight (including obesity) among adolescents and (i) neighborhood deprivation levels and (ii) food and physical activity environments of the neighborhoods they live in.

METHODS

We conducted a food and physical activity environment mapping (using ArcGIS Pro) in all neighborhoods of Oslo, which were defined by administrative boundaries (sub-districts). The neighborhood deprivation score was calculated based on the percentage of households living in poverty, unemployment in the neighborhood, and residents with low education. A cross-sectional study including 802 seventh graders from 28 primary schools in Oslo residing in 75 out of 97 sub-districts in Oslo was also performed. MANCOVA and partial correlations were ran to compare the built environment distribution between different neighborhood deprivation levels, and multilevel logistic regression analyses were used to explore the effect of neighborhood deprivation and the food and physical activity environments on childhood overweight.

RESULTS

We found that deprived neighborhoods had greater availability of fast food restaurants and fewer indoor recreational facilities compared to low-deprived neighborhoods. Additionally, we observed that the residential neighborhoods of the adolescents with overweight had greater availability of grocery and convenience stores when compared to the residential neighborhoods of the adolescents without overweight. Adolescents living in neighborhoods with high deprivation had a two-fold higher odds (95% CI = 1.1-3.8) to have overweight compared to adolescents living in neighborhoods with low deprivation, regardless of participants' ethnicity and parental education. However, the built environment did not determine the relationship between neighborhood deprivation and overweight in adolescents.

CONCLUSION

The neighborhoods in Oslo with higher deprivation levels had more obesogenic characteristics than the low-deprived neighborhoods. Adolescents living in high-deprived neighborhoods were more likely to have overweight than their counterparts from low-deprived neighborhoods. Thus, preventive measures targeting adolescents from high-deprived neighborhoods should be put in place in order to reduce incidence of overweight.

Hepatitis B and C prevalence in waste pickers: a global meta-analysis

BACKGROUND

The objective of this research was to use a meta-analysis to understand the prevalence of hepatitis B or C in waste pickers worldwide.

METHODS

Epidemiological studies on hepatitis B and C in waste pickers were included adopting a systematic review with meta-analysis. Each selected article had its quality scored by all authors, evaluated according to the Loney's criteria, and evaluated for quality and bias verified with a funnel plot.

RESULTS

After employing Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, there were 12 studies used for this meta-analysis. The rate of hepatitis B seropositivity was 0.15 (95% CI 0.10-0.20), and hepatitis C was 0.08 (95% CI 0.04-0.12). This information suggests that waste pickers are exposed to many risks associated with poor quality of life working conditions as well as low health literacy rates.

CONCLUSION

The results of this meta-analysis confirm the vulnerability of waste pickers to hepatitis B and C infection and reinforce the importance of using personal protective equipment and immunizing workers.

Racial/Ethnic Differences in Chronic Disease Predictors Among American High School Students

BACKGROUND

Few studies have attempted to define clusters of chronic disease predictors with additional focus on racial/ethnic differences. The purpose of this study was to highlight differences in predictors of chronic diseases among American high school students by identifying subgroups using latent class analysis (LCA).

METHODS

The chronic disease predictor variable used in the analysis was created from 5 modified items in the 2019 Youth Risk Behavior Surveillance that were identified to be critical to healthy lifestyles in Healthy People 2020. Descriptive, bivariate, multinomial logistic regression and LCA were performed using SAS 9.4 and Mplus in 9th to 12th grade students, using data from the Youth Risk Behavior Survey (N = 13,677).

RESULTS

Three distinct classes emerged for US high school students and were characterized as high, moderate, and low risk of chronic disease (38%, 33%, and 29%, respectively). Black and Asian students had a higher chance of being in the high-risk class of chronic diseases.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Emphasis should be placed on sociocultural and socio-environmentally structured prevention programs for at risk/students, ensuring that policy formation reflects the language, identity, and needs of the populations at risk.

CONCLUSIONS

The behavioral similarities of the classes identified highlight the need for continued research, novel interventions, and culturally sensitive strategies and policies in US high schools.

Housing mobility protects against alcohol use for children with socioemotional health vulnerabilities: An experimental design

PURPOSE

Neighborhood context may influence alcohol use, but effects may be heterogeneous, and prior evidence is threatened by confounding. We leveraged a housing voucher experiment to test whether housing vouchers' effects on alcohol use differed for families of children with and without socioemotional health or socioeconomic vulnerabilities.

TRIAL DESIGN

In the Moving to Opportunity (MTO) study, low-income families in public housing in five US cities were randomized in 1994 to 1998 to receive one of three treatments: (1) a housing voucher redeemable in a low-poverty neighborhood plus housing counseling, (2) a housing voucher without locational restriction, or (3) no voucher (control). Alcohol use was assessed 10 to 15 years later (2008 to 2010) in youth ages 13 to 20, N = 4600, and their mothers, N = 3200.

METHODS

Using intention-to-treat covariate-adjusted regression models, we interacted MTO treatment with baseline socioemotional health vulnerabilities, testing modifiers of treatment on alcohol use.

RESULTS

We found treatment effect modification by socioemotional factors. For youth, MTO voucher treatment, compared with controls, reduced the odds of ever drinking alcohol if youth had behavior problems (OR = 0.26, 95% CI [0.09, 0.72]) or problems at school (OR = 0.46, [0.26, 0.82]). MTO low-poverty treatment (vs. controls) also reduced the number of drinks if their health required special medicine/equipment (OR = 0.50 [0.32, 0.80]). Yet treatment effects were nonsignificant among youth without socioemotional vulnerabilities. Among mothers of children with learning problems, MTO voucher treatment (vs. controls) reduced past-month drinking (OR = 0.69 [0.47, 0.99]), but was harmful otherwise (OR = 1.22 [0.99, 1.45]).

CONCLUSIONS

For low-income adolescents with special needs/socioemotional problems, housing vouchers protect against alcohol use.

Effects of Housing Vouchers on the Long-Term Exposure to Neighborhood Opportunity among Low-Income Families: The Moving to Opportunity Experiment

Tenant-based rental assistance has received much attention as a tool to ameliorate American poverty and income segregation. We examined whether a tenant-based voucher program improves long-term exposure to neighborhood opportunity overall and across multiple domains-social/economic, educational, and health/environmental-among low-income families with children. We used data from the Moving to Opportunity (MTO) experiment (1994-2010) with a 10- to 15-year follow-up period and used an innovative and multidimensional measure of neighborhood opportunities for children. Compared with controls in public housing, MTO voucher recipients experienced improvement in neighborhood opportunity overall and across domains during the entire study period, with a larger treatment effect for families in the MTO voucher group who received supplementary housing counseling, than the Section 8 voucher group. Our results also suggests that effects of housing vouchers on neighborhood opportunity may not be uniform across subgroups. Results from model-based recursive partitioning for neighborhood opportunity identified several potential effect modifiers for housing vouchers, including study sites, health and developmental problems of household members, and having vehicle access.

Racial/ethnic health disparities among children with special health care needs in Boston, Massachusetts

BACKGROUND

Little is known about the factors that contribute to racial/ethnic disparities among children with special health care needs (CSHCN).

OBJECTIVE

To quantify the contributions of determinants of racial/ethnic disparities in health and health care among CSHCN in Boston, Massachusetts.

METHODS

A sample of 326 Black, Latino, and white CSHCN was drawn from the Boston Survey of Children's Health, a city-wide representative sample of children. The study implemented Oaxaca-Blinder-style decomposition techniques to examine the relative contributions of health resources and child-, family-, and neighborhood-level factors to disparities in four outcomes: health status, barriers to medical care, oral health status, and utilization of preventive dental care.

RESULTS

White CSHCN had a greater likelihood of having very good/excellent health and oral health and were less likely to experience barriers to care than Black CSHCN. Compositional differences on predictors explained 63%, 98%, and 80% of these gradients, respectively. Group variation in household income, family structure, neighborhood support, and exposure to adverse childhood experiences accounted for significant portions of the Black-white gaps in health and access. White CSHCN were also more likely to have very good/excellent health and oral health compared to Latino CSHCN. Differences on predictors accounted for about 86% and 80% of these gaps, respectively. Household income, adverse childhood experiences, and household language emerged as significant determinants of Latino-white disparities.

CONCLUSIONS

Racial/ethnic health disparities among CSHCN are explained by relatively few determinants. Several of the contributing factors that emerged from the analysis and could be targeted by public health and policy interventions.

Racial Disparities in Renal Outcomes over Time among Hospitalized Children with Systemic Lupus Erythematosus

OBJECTIVES

Racial and ethnic minority groups have excess morbidity related to renal disease in pediatric-onset systemic lupus erythematosus (SLE). We evaluated temporal trends in renal outcomes and racial disparities among hospitalized children with SLE over 14 years.

METHODS

We identified patients ≤21 years-old with discharge diagnoses of SLE in the Pediatric Health Information System® inpatient database (2006-2019). Adverse renal outcomes included end-stage renal disease (ESRD), dialysis, or transplant, analyzed as a composite and separately. We estimated the odds of adverse renal outcomes at any hospitalization, or the first occurrence of an adverse renal outcome, adjusted for calendar period, patient characteristics, and clustering by hospital. We tested whether racial disparities differed by calendar period.

RESULTS

There were 20,893 admissions for 7,434 SLE patients, of which 32%, 16%, 12% and 8% were Black, Hispanic White, Hispanic Other and Asian, respectively. Proportions of admissions with adverse renal outcomes decreased over time (p<0.01). Black children remained at highest risk of adverse renal outcomes at any admission (OR 2.5, 95% CI [1.8-3.5] vs. non-Hispanic White). Black and Asian children remained at higher risk of incident adverse renal outcomes, driven by ESRD among Black children (OR 1.6 [1.2-2.1]) and dialysis among Asians (OR 1.7 [1.1-2.7]). Relative disparities did not change significantly over time.

CONCLUSION

Significant reductions in ESRD and dialysis occurred over time for children with SLE across all racial and ethnic groups. The lack of corresponding reductions in racial disparities highlights the need for targeted interventions to achieve greater treatment benefit among higher risk groups.

Using Electronic Health Records to understand the population of local children captured in a large health system in Durham County, NC, USA, and implications for population health research

Although local policies aimed at reducing childhood health inequities can benefit from local data, sample size constraints in population representative health surveys often prevent rigorous evaluations of child health disparities and health care patterns at local levels. Electronic Health Records (EHRs) offer a possible solution as they contain large amounts of information on pediatric patients within a health system. In this paper, we consider the suitability of using EHRs from a large health system to study local children's health by evaluating the extent to which the EHRs capture the county's child population. First, we compare the demographic characteristics of Duke University Health System pediatric patients who live in Durham County, NC (USA) to the child population estimates in the 2015-2019 American Community Survey. We then examine geographic variation in census tract rates of children captured in the EHR data and estimate negative binomial models to assess how tract characteristics are associated with these rates. We also perform these analyses for the subset of pediatric patients who have a well-child encounter. We find that the demographic characteristics of pediatric patients captured by the EHRs are similar to those of the county's child population. Although the county rate of children captured in the EHRs is high, there is variation across census tracts. On average, census tracts with higher concentrations of non-Hispanic Black residents have lower capture rates and tracts with higher concentrations of poverty have higher capture rates, with the poorest tracts showing the largest racial gap in rates of children captured by EHRs. Our findings suggest that EHRs from a large health system can be used to assess children's population health, but that EHR-based evaluations of children's health disparities and health care patterns should account for differences in who is captured by the EHRs based on census tract characteristics.

Social Disparities in Benign Lung Diseases

The many socioeconomic disparities in the myriad of diagnoses that make up benign lung diseases are unfortunately a global issue that was most recently highlighted by the COVID-19 pandemic of 2020. In this chapter, we will be reviewing the socioeconomic disparities in benign lung disease from both a United States perspective as well as a global perspective. We will cover the spectrum of infectious, obstructive, and restrictive lung disease and review the evidence on how social disparities affect these populations and their access to medical care.

Connecting the biology of stress, allostatic load and epigenetics to social structures and processes

How do sociology and stress biology connect in efforts to understand the impact of early childhood adversity on health and life chances? This memorial article describes the collaboration between Bruce and Craig McEwen in bringing stress neurobiology to sociologists. It attempts, in turn, to bring sociology to stress neurobiologists, the second goal of this collaboration. It frames the social sources of human stress in terms of the social determinants of health as well as more proximal childhood adversities. It also underlines the importance of supportive adult and community relationships in preventing toxic stress. Bruce was hopeful that stress biology research could inform public health efforts aimed at improving population health and more equitable life trajectories. To strengthen our understanding of stress and to contribute to that goal, stress neurobiologists can help tease out the complex social causes of stress by expanding the range of variables employed to identify its sources as well as the protections against it in human populations.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

The Benefits of Rental Assistance for Children's Health and School Attendance in the United States

Programs that provide affordable and stable housing may contribute to better child health and thus to fewer missed days of school. Drawing on a unique linkage of survey and administrative data, we use a quasi-experimental approach to examine the impact of rental assistance programs on missed days of school due to illness. We compare missed school days due to illness among children receiving rental assistance with those who will enter assistance within two years of their interview, the average length of waitlists for federal rental assistance. Overall, we find that children who receive rental assistance miss fewer days of school due to illness relative to those in the pseudo-waitlist group. We demonstrate that rental assistance leads to a reduction in the number of health problems among children and thus to fewer days of school missed due to illness. We find that the effect of rental assistance on missed school days is stronger for adolescents than for younger children. Additionally, race-stratified analyses reveal that rental assistance leads to fewer missed days due to illness among non-Hispanic White and Hispanic/Latino children; this effect, however, is not evident for non-Hispanic Black children, the largest racial/ethnic group receiving assistance. These findings suggest that underinvestment in affordable housing may impede socioeconomic mobility among disadvantaged non-Hispanic White and Hispanic/Latino children. In contrast, increases in rental assistance may widen racial/ethnic disparities in health among disadvantaged children, and future research should examine why this benefit is not evident for Black children.

Influence of Geographic Access on Surgical Center Readmissions After Index Congenital Heart Surgery

OBJECTIVE

To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery.

STUDY DESIGN

Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression.

RESULTS

Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days.

CONCLUSIONS

Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population.

COVID-19 among Minority Children in Detroit, Michigan during the Early National Surge of the Pandemic

Background. The COVID-19 pandemic has shed light on communities of racial/ethnic minority groups in the US where long-standing health issues and structural inequities are now known to have resulted in increased risk for infection, severe illness, and death from the virus. The objective of our study was to describe demographic characteristics, clinical presentations, medical interventions and outcomes of pediatric patients with COVID-19 treated at Children’s Hospital of Michigan (CHM), a tertiary care center in urban Detroit, an early hotspot during the initial surge of the SARS-CoV-2 pandemic. Methods. A retrospective chart review was performed of children ≤18 years of age who had polymerase chain reaction (RT-PCR) testing via NP swab or serum IgG antibody testing for SARS-CoV-2 during March 1, 2020–June 30, 2020. Results. Seventy-eight COVID-19 infected children were identified of whom 85.8% (67/78) were from minority populations (African American, Hispanic). Hospitalization rate was 82% (64/78). About 44% (34/78) had an associated comorbidity with asthma and obesity being most common. Although all ages were affected, infants <1 year of age had the highest hospitalization rate (19/64, 30%). In all disease severity categories, dichotomized non-whites had more severe disease by percentage within race/ethnicity than Whites, and also within percent disease severity (P-value = .197). Overall, 37% of hospitalized patients required intensive care. Conclusions. Extremely high rates of COVID-19 hospitalization and requirement of ICU care were identified in our patient population. Further studies are needed to better understand the contributing factors to this health disparity in disadvantaged communities.

Measuring Equity From The Start: Disparities In The Health Development Of US Kindergartners

Racialized disparities in health and well-being begin early in life and influence lifelong health outcomes. Using the Early Development Instrument-a population-level early childhood health measure-this article examines potential health inequities with regard to neighborhood income and race/ethnicity in a convenience sample of 183,717 kindergartners in ninety-eight US school districts from 2010 to 2017. Our findings demonstrate a distinct income-related outcome gradient. Thirty percent of children in the lowest-income neighborhoods were vulnerable in one or more domains of health development, compared with 17 percent of children in higher-income settings. Significantly higher rates of income-related Early Development Instrument vulnerability-defined as children falling below the tenth-percentile cutoff on any Early Development Instrument domain-were demonstrated for Black/African American and Hispanic/Latinx children. These findings underscore the utility of the Early Development Instrument as a way for communities to measure child health equity gaps and inform the design, implementation, and performance of multisector place-based child health initiatives. More broadly, results indicate that for the US to make significant headway in decreasing lifelong health inequities, it is important to achieve health equity by early childhood.

Association Between Social Determinants of Health and Postoperative Outcomes in Patients Undergoing Single-Level Lumbar Fusions: A Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The aim of this study was to analyze association between social determinants of health (SDH) disparity on postoperative complication rates, and 30-day and 90-day all-cause readmission in patients undergoing single-level lumbar fusions.

SUMMARY OF BACKGROUND DATA

Decreasing postoperative complication rates is of great interest to surgeons and healthcare systems. Postoperative complications are associated with poor convalescence, inferior patient reported outcomes measures, and increased health care resource utilization. Better understanding of the association between Social Determinants of Health (SDH) on postoperative outcomes maybe helpful to decrease postoperative complication rates.

METHODS

MARINER 2020, an all-payer claims database, was utilized to identify patients undergoing single-level lumbar fusions between 2010 and 2018. The primary outcomes were the rates of any postoperative complication, symptomatic pseudarthrosis, need for revision surgery, or 30-day and 90-day all-cause readmission.

RESULTS

The exact matched population analyzed in this study contained 16,560 patients (8280 [50.0%] patients undergoing single-level lumbar fusion with an SDH disparity; 8280 [50.0%] patients undergoing single-level lumbar fusion without a disparity). Both patient groups were balanced at baseline. The rate of symptomatic pseudarthrosis (1.0% vs. 0.6%, P < 0.05) or any postoperative complication (16.3% vs. 10.4%, P < 0.05) in the matched analysis was higher in the disparity group. The presence of a disparity was associated with 70% increased odds of developing any complication (OR 1.7, 95% CI 1.53-1.84) or symptomatic pseudarthrosis (OR 1.7, 95% CI 1.17-2.37). Unadjusted and adjusted sensitivity analyses yielded similar results as the primary analysis.

CONCLUSION

Social Determinants of Health affect outcomes in spine surgery patients and are associated with an increased risk of developing postoperative complications following lumbar spine fusion.Level of Evidence: 3.

Annual Research Review: Youth firearm violence disparities in the United States and implications for prevention

OBJECTIVE

Research has identified the United States (U.S.) as a global outlier in its firearm ownership rates, with a correspondingly higher risk of youth firearm violence compared to other countries. The relative extent of disparities in youth firearm violence within the U.S. has been less clear. Little is known about factors in the social ecology driving these disparities and whether current firearm violence prevention approaches sufficiently address them.

METHOD

Applying a health disparities framework, we synthesized epidemiological, sociological, and prevention science literatures, emphasizing structural inequalities in youth sociocultural positionality in life course developmental context. We also highlighted findings from national injury data and other studies regarding the magnitude and impacts of youth firearm violence disparities.

RESULTS

The burden of firearm violence varied markedly at intersections of gender, race, place, developmental stage, and homicidal or suicidal intent. Firearm homicide among Black boys and young men (ages 15-24) was at outlier levels - many times greater than the rates of any other demographic group, developmental stage, or violence intent, particularly in urban settings. Recent research has operationalized structural racism and implicated historically racialized spaces as a root cause of this disparity. In contrast, elevated firearm suicide rates were found among Native and White boys and young men in rural settings; firearm-related cultural attitudes and gender socialization were points of consideration to explain these disparities. We highlighted research-based youth firearm violence preventive interventions, and emphasized gaps in efforts focused on structural and sociocultural factors.

CONCLUSIONS

More explicit attention to reducing firearm homicide among Black boys and young men and firearm suicide among Native and rural White boys and young men is urgently needed and has potential to substantially lower overall rates of firearm violence in the U.S.

Affordable but Inaccessible? Contraception Deserts in the US States

CONTEXT

This article focuses on whether, and the extent to which, the resources made available by Title X-the only federal policy aimed specifically at reproductive health care-are equitably accessible. Here, equitable means that barriers to accessing services are lowest for those people who need them most.

METHODS

The authors use geographic information systems (GIS) and statistical/spatial analysis (specifically the integrated two-step floating catchment area [I2SFCA] method) to study the spatial and nonspatial accessibility of Title X clinics in 2018.

FINDINGS

The authors find that contraception deserts vary across the states, with between 17% and 53% of the state population living in a desert. Furthermore, they find that low-income people and people of color are more likely to live in certain types of contraception deserts.

CONCLUSIONS

The analyses reveal not only a wide range of sizes and shapes of contraception deserts across the US states but also a range of severity of inequity.

Environmental Justice in the American Public Health Context: Trends in the Scientific Literature at the Intersection Between Health, Environment, and Social Status

Although various governmental entities in the USA are required to consider environmental justice (EJ) impacts of their actions during decision-making, socially vulnerable groups continue to be disproportionately exposed to environmental hazards. Tools and programs to quantify and mitigate environmental injustices are limited by existing data, which may not capture the full range of health disparities exacerbated by the complex interactions between environmental exposures and social stressors. In this study, we analyzed how the scientific literature approaches EJ issues in the USA. We searched PubMed for journal articles discussing at least one sociodemographic or environmental variable in the context of cumulative impacts and analyzed the relative frequency with which various EJ topics were studied. Our findings indicate that demographic variables are commonly used in epidemiologic studies, though some areas (e.g., age) are better studied than others. Similarly, occupational exposure and ambient air pollution were more studied than other types of exposures. Word frequency analyses revealed which toxicants and health outcomes are the most frequently studied. In addition, temporality analyses showed that the rate of occupational publications rose rapidly in the 1970-1980s and has since plateaued, while other publication rates increased two decades later and are still on the rise. Cumulative impacts are considered in a relatively small portion of journal articles across all topics; nevertheless, they have seen an exponential climb in the last decade. A more equitable distribution of scientific efforts might be needed for a better distribution of funding, policy-making efforts, and other resources to socially and environmentally vulnerable communities.

Dementia Care in Diverse Older Adults in the U.S. Deep South and the Rest of the United States

BACKGROUND

Use of specialists and recommended drugs has beneficial effects for older adults living with Alzheimer's disease and related dementia (ADRD). Gaps in care may exist for minorities, e.g., Blacks, and especially in the United States (U.S.) Deep South (DS), a poor U.S. region with rising ADRD cases and minority overrepresentation. Currently, we have little understanding of ADRD care utilization in diverse populations in this region and elsewhere in the U.S. (non-DS), and the factors that adversely impact it.

OBJECTIVE

To examine utilization of specialists and ADRD drugs (outcomes) in racial/ethnic groups of older adults with ADRD and the personal or context-level factors affecting these outcomes in DS and non-DS.

METHODS

We obtained outcomes and personal-level covariates from claims for 127,512 Medicare beneficiaries with ADRD in 2013-2015, and combined county-level data in exploratory factor analysis to define context-level covariates. Adjusted analyses tested significant association of outcomes with Black/White race and other factors in DS and non-DS.

RESULTS

Across racial/ethnic groups, 33%-43% in DS and 43%-50% in non-DS used specialists; 47%-55% in DS and 41%-48% in non-DS used ADRD drugs. In adjusted analyses, differences between Blacks and Whites were not significant. Vascular dementia, comorbidities, poverty, and context-level factor "Availability of Medical Resources" were associated with specialist use; Alzheimer's disease and senile dementia, comorbidities, and specialist use were associated with drug use. In non-DS only, other individual, context-level covariates were associated with the outcomes.

CONCLUSION

We did not observe significant gaps in ADRD care in DS and non-DS; however, research should further examine determinants of low specialist and drug use in these regions.

Contextual risks and psychosocial outcomes among rural African American emerging adults: A latent profile analysis

African American emerging adults face unique contextual risks that place them at heightened risk for poor psychosocial outcomes. The purpose of this study was to identify profiles of contextual risks among rural African American emerging adults and determine how risk profiles relate to psychosocial outcomes. Our representative sample included 667 fifth graders who live in the rural South and were followed from preadolescence into emerging adulthood. Contextual risks were assessed at ages 19-21 years via six indicators: perceived stress, daily stress, community disadvantage, parent-child conflict, racial discrimination, and childhood trauma. Four psychosocial variables were also assessed at ages 19-21 years: self-regulation, racial identity, parent support, and friend support. Psychosocial outcomes were assessed at age 25 years: education, substance use, future orientation, depressive symptoms, and externalizing behaviors. Latent profile analysis results indicated that the sample could be characterized by three patterns of contextual risk: low contextual risk, high contextual risk, and high contextual risk-childhood trauma. Risk profiles were associated with psychosocial outcomes, with the childhood trauma and high-risk profiles faring worse than the low-risk profile. Further, childhood trauma was particularly predictive of worse outcomes for emerging adults. Findings highlight the need for research and prevention programs that mitigate the effects of contextual risks on psychosocial outcomes for African American emerging adults in rural areas.

Associations between ethnicity, place of residence, hearing status of family and habilitation of children with hearing impairment

Background

Hearing parents tend to have a strong preference for their deaf and hard-of-hearing children to acquire adequate speech, as opposed to use of sign language. Research reports the contribution of many variables to speech acquisition by children with hearing loss (HL). Yet, little is known about the association between ethnicity, place of residence, and hearing status of family members and mode of communication of young people with HL. The purpose of the present study was to examine whether mode of communication of young people with HL is associated with ethnicity, place of residence, and hearing status of family members.

Method

Participants were young adults with sensory-neural severe to profound HL, either congenital or acquired prior to age 3. Only participants without additional disabilities were included. The data on participants were extracted from records of the Ministry of Labor, Social Affairs and Social Services in Israel. The data for each participant in the study included mode of communication, gender, use of assistive device, ethnicity, geographic place of residence, and presence of first-degree relatives with HL. Regarding participants with a cochlear implant (CI), age at implantation was documented as well.

Results

Chi-square tests revealed significant associations between mode of communication and all of the study variables. In addition, all the study variables made a significant contribution to mode of communication. Regarding ethnicity, most of the ultra-Orthodox participants used oral language, while the majority of Israeli-Arab participants used sign language. Regarding geographical place of residence, lower rates of oral language use were found in the northern and southern districts of Israel.

Conclusions

The findings of the present study underline the need for better monitoring of Israeli-Arab children with HL and children residing in peripheral areas in Israel and for improving access to habilitation services.

The intersectional effect of poverty, home ownership, and racial/ethnic composition on mean childhood blood lead levels in Milwaukee County neighborhoods

Environmental conditions that contribute to childhood lead exposure are spatially patterned. Socioeconomic and racial inequities in childhood lead exposure have been well documented, however childhood lead exposure in Milwaukee is understudied. As a segregated rustbelt metropolitan area with childhood lead exposure concerns, Milwaukee is uniquely positioned to evaluate the synergistic effects of racial and economic drivers of childhood lead exposure. Using surveillance data from the Wisconsin Department of Health Services, Division of Public Health and the US Census Bureau, this cross-sectional study determined the intersectional effect of poverty, home ownership, and racial/ethnic composition on childhood lead exposure in Milwaukee County neighborhoods using linear regression adjusting for average census tract housing age and number of children. The final analytical sample consisted of 48,393 individual childhood blood lead levels aggregated to 215 Milwaukee County census tracts. Census tracts with mean childhood blood lead levels greater than or equal to 5 μg/dL were predominantly low home ownership, high poverty, and majority non-White census tracts. The effects of low home ownership, high poverty, and majority non-White census tracts were synergistic, producing 1.78 (95% CI: 1.44, 2.11) μg/dL higher mean childhood blood lead level than high home ownership, low poverty, and majority White census tracts (referent). This research reveals that social determinants at the neighborhood level co-occur and interact to produce inequities in childhood lead exposure. Lead prevention efforts should align with equity-focused housing and economic policies that target primary prevention in neighborhoods disproportionately burdened by childhood lead exposure.

The Association Between Neighborhood Socioeconomic Disadvantage and Chronic Obstructive Pulmonary Disease

Rationale

Individual socioeconomic status has been shown to influence the outcomes of patients with chronic obstructive pulmonary disease (COPD). However, contextual factors may also play a role. The objective of this study is to evaluate the association between neighborhood socioeconomic disadvantage measured by the area deprivation index (ADI) and COPD-related outcomes.

Methods

Residential addresses of SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) subjects with COPD (FEV₁/FVC <0.70) at baseline were geocoded and linked to their respective ADI national ranking score at the census block group level. The associations between the ADI and COPD-related outcomes were evaluated by examining the contrast between participants living in the most-disadvantaged (top quintile) to the least-disadvantaged (bottom quintile) neighborhood. Regression models included adjustment for individual-level demographics, socioeconomic variables (personal income, education), exposures (smoking status, packs per year, occupational exposures), clinical characteristics (FEV₁% predicted, body mass index) and neighborhood rural status.

Results

A total of 1800 participants were included in the analysis. Participants residing in the most-disadvantaged neighborhoods had 56% higher rate of COPD exacerbation (P<0.001), 98% higher rate of severe COPD exacerbation (P=0.001), a 1.6 point higher CAT score (P<0.001), 3.1 points higher SGRQ (P<0.001), and 24.6 meters less six-minute walk distance (P=0.008) compared with participants who resided in the least disadvantaged neighborhoods.

Conclusion

Participants with COPD who reside in more-disadvantaged neighborhoods had worse COPD outcomes compared to those residing in less-disadvantaged neighborhoods. Neighborhood effects were independent of individual-level socioeconomic factors, suggesting that contextual factors could be used to inform intervention strategies targeting high-risk persons with COPD.

Antibiotic burden of school children from Tibetan, Hui, and Han groups in the Qinghai-Tibetan Plateau

BACKGROUND

Given their geographical proximity but differences in cultural and religious dietary customs, we hypothesize that children from the three main ethnic populations (Han, Hui, and Tibetan) residing in the Qinghai-Tibetan Plateau region differs in their non-iatrogenic antibiotic loads.

METHODS

To determine the antibiotic burden of the school children unrelated to medical treatment, we quantified the antibiotic residues in morning urine samples from 92 Han, 72 Tibetan, and 85 Muslim Hui primary school children aged 8 to 12 years using high-performance liquid chromatography-tandem mass spectrometry, and performed correlation analysis between these data and concurrent dietary nutrition assessments.

RESULTS

Sixteen of the 18 targeted antibiotics (4 macrolides, 3 β-lactams, 2 tetracyclines, 4 quinolones, 3 sulfonamides, and 2 aminoanols) were identified in the urine samples with an overall detection frequency of 58.63%. The detection frequency of the six antibiotic classes ranged from 1.61% to 32.53% with ofloxacin showing the single highest frequency (18.47%). Paired comparison analysis revealed significant differences in antibiotic distribution frequency among groups, with Tibetans having higher enrofloxacin (P = 0.015) and oxytetracycline (P = 0.021) than Han children. Norfloxacin (a human/veterinary antibiotic) was significantly higher in the Hui children than in the Han children (P = 0.024). Dietary nutrient intake assessments were comparable among participants, showing adequate levels of essential vitamins and minerals across all three ethnic groups. However, significant differences in specific foods were observed among groups, notably in lower fat consumption in the Hui group.

CONCLUSIONS

The introduction and accumulation of antibiotic residues in school children through non-iatrogenic routes (food or environmental sources) poses a serious potential health risk and merits closer scrutiny to determine the sources. While the exact sources of misused or overused antibiotics remains unclear, further study can potentially correlate ethnicity-specific dietary practices with the sources of contamination.

What Is Population Health?

This article defines population health as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. Attention to social and environmental, as well as medical, determinants of health is essential. The population health lens can be used at the individual, practice, institutional, and community levels. The need for primary care to engage in population health stems from the importance of social and environmental factors, the nature of primary care, and contextual changes.

Residential Mobility Among Elementary School Students in Los Angeles County and Early School Experiences: Opportunities for Early Intervention to Prevent Absenteeism and Academic Failure

School connectedness is closely linked to academic success: students who are engaged at school have better attendance and academic performance, and are less likely to drop out. Residential mobility – having moved homes – can increase the risk of a negative academic trajectory (e.g., absenteeism and academic failure). Increasing housing instability in the United States due to rising housing costs, especially in urban areas, has made residential mobility a growing concern. While existing research has examined residential mobility among students and its connection to long-term consequences such as absenteeism and academic failure, less is known about how residential mobility relates to potential intermediate school experiences (e.g., school disconnectedness, low perceived academic ability, and experiences with school violence and harassment) that contribute to a negative academic trajectory. This study examines associations between residential mobility in elementary school and school experiences in a large urban jurisdiction. Data were collected from a sample of public elementary school students in Los Angeles County (5th grade, n = 5,620) via the California Healthy Kids Survey (2013–2014). Descriptive, Chi-square, multiple logistic regression analyses, and predicted probabilities were performed to examine the relationships between past-year residential mobility and indicators of school connectedness and school-based relationships, perceived academic performance, and exposure to violence and harassment. More than a third (36.6%) of students in the analysis sample moved at least once in the past year. After adjusting for neighborhood and family factors, a higher number of past-year moves was significantly associated with poorer school experiences, including lower odds of school connectedness for high-movers (2+ moves) [adjusted odds ratio (AOR) = 0.77; 95% confidence interval (CI) = 0.68–0.86], compared to non-movers. Movers had lower odds of perceived academic ability (1 move: AOR = 0.72; CI = 0.63–0.83; 2+ moves: AOR = 0.55; CI = 0.44–0.69), but higher odds of exposure to violence and harassment as a victim (1 move: AOR = 1.26, CI = 1.17–1.37; 2+ moves: AOR = 1.34, CI = 1.17–1.54), and as a perpetrator (1 move: AOR = 1.21, CI = 1.08–1.36; 2+ moves: AOR = 1.54, CI = 1.24–1.92). These results highlight the value of developing and implementing strategies that can identify and support students who move at young ages, to prevent student disengagement and promote attendance and academic success early in their life trajectory.

Spatial analysis of factors influencing choice of paediatric practice for mothers from low-income and minority populations

AIM

Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data.

METHODS

In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another.

RESULTS

A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05).

CONCLUSIONS

The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

Higher Peripheral Inflammatory Signaling Associated With Lower Resting-State Functional Brain Connectivity in Emotion Regulation and Central Executive Networks

BACKGROUND

Researchers document bidirectional pathways linking peripheral inflammation and neural circuitries subserving emotion processing and regulation. To extend this work, we present results from two independent studies examining the relationship between inflammation and resting-state functional connectivity (rsFC), as measured by functional magnetic resonance imaging.

METHODS

Study 1 involved 90 rural African American young adults, 25 years of age (52% female), and study 2 involved 82 urban African American youths, 13 to 14 years of age (66% female). Both studies measured circulating inflammatory biomarkers (C-reactive protein, interleukin 6, interleukin 10, tumor necrosis factor alpha), and the measures were averaged to form a composite. Study 2 also enumerated classical monocytes, a key leukocyte subpopulation involved in immune-to-brain signaling. All participants completed a resting-state functional magnetic resonance imaging scan.

RESULTS

Consistent with our prediction, higher scores on the inflammatory composite were associated with lower rsFC within an emotion regulation network in study 1, controlling for sex. Study 2 replicated study 1, showing that higher scores on the inflammatory composite were associated with lower rsFC within the emotion regulation network, controlling for sex, age, and pubertal status, and found a similar pattern for rsFC within a central executive network. Study 2 also found that higher numbers of classical monocytes were associated with lower rsFC within both the emotion regulation and central executive networks. There was no relationship between rsFC in the anterior salience or default mode networks with inflammation in either study.

CONCLUSIONS

With these findings, we document relationships between peripheral inflammation and rsFC within an emotion regulation and central executive network and replicate these associations with the emotion regulation network across two independent samples.

Treatment Utilization Trajectories among Children with Autism Spectrum Disorder: Differences by Race-Ethnicity and Neighborhood

Health coverage of early intensive behavioral intervention (EIBI) for children with autism spectrum disorder is expanding. Yet there is no longitudinal research on patterns of or inequities in utilization of EIBI. We integrated state administrative records with Medicaid and Census data for children enrolled in an EIBI Medicaid waiver (N = 730) to identify and describe the type and prevalence of treatment utilization trajectories, and to examine the association between trajectory types and (a) child race-ethnicity and (b) neighborhood racial composition, poverty, affluence, and urbanicity. We identified four utilization trajectories (Low, Low-Moderate, Moderate, and High users). Race-ethnicity and neighborhood affluence were associated with trajectory membership. As coverage expands, policy makers should consider strategies to improve overall treatment utilization and enhance equity.

Epidemiology of hepatitis B virus infection in people living in poverty in the central-west region of Brazil

Background

People living in poverty (PLP) are highly vulnerable to hepatitis B virus (HBV) infection. This study aimed to investigate the epidemiology of HBV infection in PLP in the metropolitan region of Goiânia, Goiás State, in the Central-West Region of Brazil.

Methods

A cross-sectional study was conducted from August to December 2016 in adults aged ≥12 years living in poverty. The following serological markers for HBV were investigated: hepatitis B surface antigen (HBsAg), antibody to HBV core antigen (total anti-HBc), IgM anti-HBc, and hepatitis B surface antibody (anti-HBs), which were detected by enzyme-linked immunosorbent assay (ELISA). Poisson regression analysis with robust variance was performed to verify the factors associated with HBV exposure.

Results

The study included 378 participants. The overall prevalence rate of HBV (any viral marker) was 9.8% (95% confidence interval [CI], 7.2–13.2). The prevalence rate of HBsAg in combination with total anti-HBc was 0.8% (95% CI, 0.3–2.4), total anti-HBc in combination with anti-HBs was 7.7% (95% CI, 5.4–10.9), and total anti-HBc alone was 1.3% (95% CI, 0.5–3.0) in the population. Furthermore, isolated positivity for anti-HBs was identified in only 25.4% (95% CI, 21.3–30.0) of the participants. Multiple regression analysis revealed that age (adjusted prevalence ratio [APR], 1.04; 95% CI, 1.01–1.07), female sex (APR, 2.18; 95% CI, 1.01–4.73), sexual intercourse under the influence of alcohol (APR, 2.49; 95% CI, 1.36–7.06), and exposure to Treponema pallidum (APR, 3.10; 95% CI, 1.36–7.06) were associated with HBV exposure.

Conclusion

There was a high prevalence of HBV exposure in PLP in the Central-West Region of Brazil, indicating significant viral spread of the infection. Additionally, there was low serological evidence of immunisation against hepatitis B, indicating that a large proportion of the participants in this study are susceptible to the infection. The results support the need for public health policies that facilitate access to the existing healthcare services in hard-to-reach groups with special regard to immunisation programmes against hepatitis B.

Time-Lag Between Diagnosis of Autism Spectrum Disorder and Onset of Publicly-Funded Early Intensive Behavioral Intervention: Do Race-Ethnicity and Neighborhood Matter?

Health coverage of early intensive behavioral intervention (EIBI) for children with autism spectrum disorder (ASD) is rapidly expanding across the United States. Yet we know little about the time-lag between diagnosis and treatment onset. We integrated administrative, Medicaid claims, and Census data for children in an EIBI Medicaid waiver (n = 473) to examine the relationship between time-lag and (a) child race-ethnicity and (b) neighborhood racial composition, poverty, affluence, and urbanicity. We explored whether the relationship between child race-ethnicity and time-lag varies by neighborhood characteristics. Average time-lag between diagnosis and treatment onset was nearly 3 years. Child race-ethnicity and neighborhood characteristics did not predict time-lag. Reducing time-lag is critical to ensuring that children with ASD receive treatment as early as possible.

Separate and Sick: Residential Segregation and the Health of Children and Youth in Metropolitan Statistical Areas

The purpose of this study was to better understand residential segregation and child/youth health by examining the relationship between a measure of Black-White residential segregation, the index of dissimilarity, and a suite of child and youth health measures in 235 U.S. metropolitan statistical areas (MSAs). MSAs are urban areas with a population of 50,000 or more and adjacent communities that share a high degree of economic and social integration. MSAs are defined by the Office of Management and Budget. Health-related measures included child mortality (CDC WONDER), teen births (NCHS natality data), children in poverty (SAIPE program), and disconnected youth (Measure of America). Simple linear regression and two-level hierarchical linear regression models, controlling for income, total population, % Black, and census region, examined the association between segregation and Black health, White health, and Black-White disparities in health. As segregation increased, Black children and youth had worse health across all four measures, regardless of MSA total and Black population size. White children and youth in small MSAs with large Black populations had worse levels of disconnected youth and teen births with increasing segregation, but no associations were found for White children and youth in other MSAs. Segregation worsened Black-White health disparities across all four measures, regardless of MSA total and Black population size. Segregation adversely affects the health of Black children in all MSAs and White children in smaller MSAs with large Black populations, and these effects are seen in measures that span all of childhood. Residential segregation may be an important target to consider in efforts to improve neighborhood conditions that influence the health of families and children.

Mapping inequality: Childhood asthma and environmental injustice, a case study of St. Louis, Missouri

As a geographic continuum of poverty and affluence has emerged, so too has a geographic continuum of good and poor health. Asthma is currently one of the most prevalent chronic childhood diseases. Over the past three decades, the greatest increases in asthma rates have been in urban areas and have disproportionately affected youth in poverty and those in racial and ethnic minority groups. Neighborhoods serve as a mechanism fostering environmental injustice and perpetuating these disparities in health outcomes and life opportunity for our most vulnerable populations. Using Geographic Information Systems (GIS) methods in a case study of St. Louis Missouri, this study examines local environmental risk by identifying 'hotspots,' or statistically significant spatial clustering of high or low levels of childhood asthma, and associations with neighborhood characteristics, socio-demographic characteristics, and access to healthcare resources within these hotspots. Results revealed statistically significant clustering of high asthma rates in areas with more non-White and poor residents, higher rates of public housing, deteriorating housing, and violent crime. High asthma hotspots were also located in areas with limited physical access to healthcare resources, such as physicians and medication, and lower school attendance rates. Residents of these high asthma hotspots experience greater environmental risk, and significant disparities in health and education outcomes, physical and financial healthcare resources, and overall well-being. This study demonstrates these place-based inequalities and presents clear evidence of environmental injustice, supporting the need for investments and interventions to improve the environments, health, and economic resources of our most vulnerable youth.

Neighborhood Social Context and Kidney Function Over Time: The Multi-Ethnic Study of Atherosclerosis

RATIONALE & OBJECTIVE

Although socioeconomic status has been associated with chronic kidney disease (CKD), little is known about its relationship to residential neighborhood context.

STUDY DESIGN

Secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study designed to investigate the development and progression of subclinical cardiovascular disease.

SETTING & PARTICIPANTS

6,814 men and women who were between 45 and 84 years of age and free of cardiovascular disease were recruited between 2000 and 2002 from Baltimore, MD; Chicago, IL; Forsyth County, NC; Los Angeles, CA; New York, NY; and St. Paul, MN.

EXPOSURES

A composite neighborhood problem score (calculated based on 7 participant-reported domains at study entry: adequacy of food sources, availability of parks/playground, noise, sidewalks, traffic, trash and litter, and violence) and a social cohesion score (calculated based on 5 participant-reported attributes of people in their neighborhood: close knit; get along; willing to help neighbors; trustworthy; and share values).

OUTCOMES

Estimated glomerular filtration rate (eGFR; calculated using the CKD-EPI [CKD Epidemiology Collaboration] creatinine-cystatin C equation) and an indicator of eGFR decline > 30% since study entry using follow-up eGFR quantified at 4 examinations: 2000 to 2002, 2004 to 2005, 2005 to 2007, and 2010 to 2011.

ANALYTICAL APPROACH

Associations between each neighborhood measure (in separate models) and eGFR decline > 30% from baseline and annualized eGFR change were estimated using Cox proportional hazards and linear mixed regression models, respectively, adjusting for potential confounders.

RESULTS

While neighborhood social context differs by race/ethnicity, neither neighborhood problems nor social cohesion was independently associated with eGFR decline after adjustment for confounders.

LIMITATIONS

Incomplete capture of the early stages of eGFR decline, reliance on observational data, limited variation in neighborhood measures, and the potential for residual confounding.

CONCLUSIONS

Although we showed no independent association between neighborhood context and eGFR decline, it is associated with many CKD risk factors and further work is needed to clarify whether it has an independent role in CKD.

Are We Serving the Most At-Risk Communities? Examining the Reach of a South Carolina Home Visiting Program

In addition to individual-level characteristics, characteristics of the social and physical environments in which individuals reside may adversely impact health outcomes. Careful attention to the role of "place" can result in programs that successfully deliver services to those most at risk. This retrospective, cross-sectional study used geocoded residential addresses from 3090 households enrolled in a South Carolina (SC) home visiting program, 2013-2016, and corresponding years of data for maternal and child health outcomes obtained from vital records data. ZIP Code Tabulation Areas (ZCTAs) served as the primary geographic unit of analysis. ZCTAS with high volumes of birth or adverse maternal and child health outcomes for any of 10 indicators were flagged. Distribution of enrolled households across highest-risk ZCTAs was calculated. Of 379 ZCTAS with reported data, 152 had 8 or more risk flags. Of the 152 highest-risk ZCTAs, 33 also had high birth volumes. Fifty-seven of the 152 highest-risk ZCTAs had no enrollees; seven of the 33 highest-risk/highest-volume ZCTAS had no enrollees. Service delivery gaps existed despite a statewide, county-level needs assessment conducted prior to program implementation. This study suggests methods to identify service areas of need, as an ongoing effort toward program improvement.

Modification of Housing Mobility Experimental Effects on Delinquency and Educational Problems: Middle Adolescence as a Sensitive Period

Residential mobility is one documented stressor contributing to higher delinquency and worse educational outcomes. Sensitive period life course models suggest that certain developmental stages make individuals more susceptible to the effects of an exposure, like residential mobility, on outcomes. However, most prior research is observational, and has not examined heterogeneity across age or gender that may inform sensitive periods, even though it may have important implications for the etiology of adolescent development. Moreover, there are important translational implications for identifying the groups most vulnerable to residential mobility to inform how to buffer adverse effects of moving. In this study, low-income families were randomized to residential mobility out of public housing into lower poverty neighborhoods using a rental subsidy voucher ("experimental voucher condition"), and were compared to control families remaining in public housing. The sample was comprised of 2829 youth (51% female; 62% Non-Hispanic Black, 31% Hispanic, 7% other race). At baseline, youth ranged from 5 to 16 years old. This study hypothesized that random assignment to the housing voucher condition would generate harmful effects on delinquency and educational problems, compared to the control group, among boys who were older at baseline. The results confirmed this hypothesis: random assignment to the experimental voucher condition generating residential mobility caused higher delinquency among boys who were 13-16 years old at baseline, compared to same-age, in-place public housing controls. However, residential mobility did not affect delinquency among girls regardless of age, or among boys who were 5-12 years old at baseline. The pattern of results for educational problems was similar but weaker. Families with teenage boys are particularly vulnerable to residential transitions. Incorporating additional supports into housing programs may help low-income, urban families to successfully transition to lower poverty neighborhoods.

Stereotyping across intersections of race and age: Racial stereotyping among White adults working with children

This study examined the prevalence of racial/ethnic stereotypes among White adults who work or volunteer with children, and whether stereotyping of racial/ethnic groups varied towards different age groups. Participants were 1022 White adults who volunteer and/or work with children in the United States who completed a cross-sectional, online survey. Results indicate high proportions of adults who work or volunteer with children endorsed negative stereotypes towards Blacks and other ethnic minorities. Respondents were most likely to endorse negative stereotypes towards Blacks, and least likely towards Asians (relative to Whites). Moreover, endorsement of negative stereotypes by race was moderated by target age. Stereotypes were often lower towards young children but higher towards teens.

Life-course neighbourhood opportunity and racial-ethnic disparities in risk of preterm birth

BACKGROUND

Neighbourhood opportunity, measured by poverty, income and deprivation, has been associated with preterm birth, however little is known about the contribution of early-life and life-course neighbourhood opportunity to preterm birth risk and racial-ethnic disparities. We examined maternal early-life and adult neighbourhood opportunity in relation to risk of preterm birth and racial-ethnic disparities in a population-based cohort of women under age 30.

METHODS

We linked census tract poverty data to 2 generations of California births from 1982-2011 for 403 315 white, black, or Latina mothers-infant pairs. We estimated the risk of preterm birth, and risk difference (RD) comparing low opportunity (≥20% poverty) in early life or adulthood to high opportunity using targeted maximum likelihood estimation.

RESULTS

At each time point, low opportunity was related to increased preterm birth risk compared to higher opportunity neighbourhoods for white, black and Latina mothers (RDs 0.3-0.7%). Compared to high opportunity at both time points, risk differences were generally highest for sustained low opportunity (RD 1.5, 1.3, and 0.7% for white, black and Latina mothers, respectively); risk was elevated with downward mobility (RD 0.7, 1.3, and 0.4% for white, black and Latina mothers, respectively), and with upward mobility only among black mothers (RD 1.2%). The black-white preterm birth disparity was reduced by 22% under high life-course opportunity.

CONCLUSIONS

Early-life and sustained exposure to residential poverty is related to increased PTB risk, particularly among black women, and may partially explain persistent black-white disparities.