Neighborhood Deprivation is Associated with Increased Risk of Prenatal Smoke Exposure

Neighborhood deprivation in relation to ovarian reserve and outcomes of ovarian stimulation among oocyte donors

OBJECTIVE

To study the relationship between neighborhood deprivation index (NDI) and markers of ovarian reserve and outcomes of controlled ovarian stimulation among young, healthy oocyte donors.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 547 oocyte donors who underwent 905 oocyte retrieval cycles (2008-2020) at a private fertility center in Sandy Springs, Georgia, United States.

INTERVENTIONS

Neighborhood deprivation index was calculated using principal component analysis applied to census-level measures of poverty, employment, household composition, and public assistance, which was then standardized and linked to donor information on the basis of donor residence.

MAIN OUTCOME MEASURES

Markers of ovarian reserve, including antral follicle count (AFC) and antimüllerian hormone (AMH) levels, and outcomes of controlled ovarian stimulation including number of total and mature oocytes retrieved and ovarian sensitivity index (OSI) (defined as the number of oocytes retrieved/total gonadotropin dose × 1,000). Multivariable generalized estimating equations with Poisson and normal distribution were used to model the relationship between NDI and outcome measures adjusting for age, body mass index, and year of retrieval.

RESULTS

The mean (SD) age of donors was 25.0 (2.8) years and 29% of the donors were racial or ethnic minorities. There were no associations between donor NDI and ovarian reserve markers. For every interquartile range increase in NDI, there was a reduction of -1.5% (95% confidence interval: -5.3% to 2.4%) in total oocytes retrieved although the effect estimate was imprecise. Associations of NDI with a number of mature oocytes retrieved and OSI were in a similar direction. We observed evidence for effect modification of the NDI and OSI association by donor race. There was a suggestive positive association between NDI and OSI in Black donors but no association in White donors.

CONCLUSION

In this cohort of young, healthy, racially diverse oocyte donors, we found little evidence of associations between NDI and markers of ovarian reserve or outcomes of ovarian stimulation.

Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants

BACKGROUND

Opioid use disorder is a leading cause of death through the year postpartum.

OBJECTIVE

This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people.

STUDY DESIGN

This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively.

RESULTS

Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247).

CONCLUSION

Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.

Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum

The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.

Neighborhood Deprivation, Indoor Chemical Concentrations, and Spatial Risk for Childhood Leukemia

Leukemia is the most common childhood cancer in industrialized countries, and the increasing incidence trends in the US suggest that environmental exposures play a role in its etiology. Neighborhood socioeconomic status (SES) has been found to be associated with many health outcomes, including childhood leukemia. In this paper, we used a Bayesian index model approach to estimate a neighborhood deprivation index (NDI) in the analysis of childhood leukemia in a population-based case-control study (diagnosed 1999 to 2006) in northern and central California, with direct indoor measurements of many chemicals for 277 cases and 306 controls <8 years of age. We considered spatial random effects in the Bayesian index model approach to identify any areas of significantly elevated risk not explained by neighborhood deprivation or individual covariates, and assessed if groups of indoor chemicals would explain any elevated spatial risk areas. Due to not all eligible cases and controls participating in the study, we conducted a simulation study to add non-participants to evaluate the impact of potential selection bias when estimating NDI effects and spatial risk. The results in the crude model showed an odds ratio (OR) of 1.06 and 95% credible interval (CI) of (0.98, 1.15) for a one unit increase in the NDI, but the association became slightly inverse when adjusting for individual level covariates in the observed data (OR = 0.97 and 95% CI: 0.87, 1.07), as well as when using simulated data (average OR = 0.98 and 95% CI: 0.91, 1.05). We found a significant spatial risk of childhood leukemia after adjusting for NDI and individual-level covariates in two counties, but the area of elevated risk was partly explained by selection bias in simulation studies that included more participating controls in areas of lower SES. The area of elevated risk was explained when including chemicals measured inside the home, and insecticides and herbicides had greater effects for the risk area than the overall study. In summary, the consideration of exposures and variables at different levels from multiple sources, as well as potential selection bias, are important for explaining the observed spatial areas of elevated risk and effect estimates.

Tobacco Retail Outlets, Neighborhood Deprivation and the Risk of Prenatal Smoke Exposure

INTRODUCTION

Smoking and smoke exposure among pregnant women remain persistent public health issues. Recent estimates suggest that approximately one out of four nonsmokers have measurable levels of cotinine, a marker indicating regular exposure to secondhand smoke. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy. However, most of these studies have relied upon self-reported measures of smoking.

AIMS AND METHODS

To more accurately assess smoke exposure resulting from both smoking and secondhand exposure in mothers during pregnancy, we used Bayesian regression models to estimate the association of cotinine levels with tobacco retail outlet (TRO) exposure and a neighborhood deprivation index (NDI) in six counties in North Carolina centered on Durham County.

RESULTS

Results showed a significant positive association between TRO exposure (β = 0.008, 95% credible interval (CI) = [0.003, 0.013]) and log cotinine after adjusting for individual covariates (eg, age, race/ethnicity, education, marital status). TRO exposure was not significant after including the NDI, which was significantly associated with log cotinine (β = 0.143, 95% CI = [0.030, 0.267]). However, in a low cotinine stratum (indicating secondhand smoke exposure), TRO exposure was significantly associated with log cotinine (β = 0.005, 95% CI = [0.001, 0.009]), while in a high cotinine stratum (indicating active smoking), the NDI was significantly associated with log cotinine (β = 0.176, 95% CI = [0.005, 0.372]).

CONCLUSIONS

In summary, our findings add to the evidence that contextual factors are important for active smoking during pregnancy.

IMPLICATIONS

In this study, we found several significant associations that suggest a more nuanced understanding of the potential influence of environmental- and individual-level factors for levels of prenatal smoke exposure. Results suggested a significant positive association between TRO exposure and cotinine levels, after adjusting for the individual factors such as race, education, and marital status. Individually, NDI was similarly positively associated with cotinine levels as well. However, when combining TRO exposure alongside NDI in the same model, TROs were no longer significantly associated with overall cotinine levels.

Spatially Varying Associations of Neighborhood Disadvantage with Alcohol and Tobacco Retail Outlet Rates

More than 30% of cancer related deaths are related to tobacco or alcohol use. Controlling and restricting access to these cancer-causing products, especially in communities where there is a high prevalence of other cancer risk factors, has the potential to improve population health and reduce the risk of specific cancers associated with these substances in more vulnerable population subgroups. One policy-driven method of reducing access to these cancer-causing substances is to regulate where these products are sold through the placement and density of businesses selling tobacco and alcohol. Previous work has found significant positive associations between tobacco, alcohol, and tobacco and alcohol retail outlets (TRO, ARO, TARO) and a neighborhood disadvantage index (NDI) using Bayesian shared component index modeling, where NDI associations differed across outlet types and relative risks varied by population density (e.g., rural, suburban, urban). In this paper, we used a novel Bayesian index model with spatially varying effects to explore spatial nonstationarity in NDI effects for TROs, AROs, and TAROs across census tracts in North Carolina. The results revealed substantial variation in NDI effects that varied by outlet type. However, all outlet types had strong positive effects in one coastal area. The most important variables in the NDI were percent renters, Black racial segregation, and the percentage of homes built before 1940. Overall, more disadvantaged areas experienced a greater neighborhood burden of outlets selling one or both of alcohol and tobacco.