Neighborhood-Level Interventions to Improve Childhood Opportunity and Lift Children Out of Poverty

Association Between the COI and Excess Health Care Utilization and Costs for ACSC

BACKGROUND AND OBJECTIVES

The authors of previous work have associated the Childhood Opportunity Index (COI) with increased hospitalizations for ambulatory care sensitive conditions (ACSC). The burden of this inequity on the health care system is unknown. We sought to understand health care resource expenditure in terms of excess hospitalizations, hospital days, and cost.

METHODS

We performed a retrospective cross-sectional study of the Pediatric Health Information Systems database, including inpatient hospitalizations between January 1, 2016 and December 31, 2022 for children <18 years of age. We compared ACSC hospitalizations, mortality, and cost across COI strata.

RESULTS

We identified 2 870 121 hospitalizations among 1 969 934 children, of which 44.5% (1 277 568/2 870 121) were for ACSCs. A total of 49.1% (331 083/674 548) of hospitalizations in the very low stratum were potentially preventable, compared with 39.7% (222 037/559 003) in the very high stratum (P < .001). After adjustment, lower COI was associated with higher odds of potentially preventable hospitalization (odds ratio 1.18, 95% confidence interval [CI] 1.17-1.19). Compared with the very high COI stratum, there were a total of 137 550 (95% CI 134 582-140 517) excess hospitalizations across all other strata, resulting in an excess cost of $1.3 billion (95% CI $1.28-1.35 billion). Compared with the very high COI stratum, there were 813 (95% CI 758-871) excess deaths, with >95% from the very low and low COI strata.

CONCLUSIONS

Children with lower neighborhood opportunity have increased risk of ACSC hospitalizations. The COI may identify communities in which targeted intervention could reduce health care utilization and costs.

Screening for economic hardship at Child Health Care Centres: A qualitative study of stakeholders' perceptions and experiences of the Healthier Wealthier Families model in Sweden

AIMS

The Healthier Wealthier Families model uses the child healthcare services as an access point to screen and connect parents experiencing economic hardship to municipal Budget and Debt Counselling services. This study aimed to explore the perceptions and experiences of the Healthier Wealthier Families model in a Swedish context.

METHODS

Semi-structured interviews were conducted with three stakeholder groups: eligible parents who declined (n=10) and received (n=9) financial counselling; nurses (n=7); and financial counsellors (n=5). The data were analysed using thematic analysis.

RESULTS

The analysis resulted in three main themes conveying the stigma of talking about finance, the connection between economic situation and family wellbeing, and the nuts and bolts of providing preventive financial counselling.

CONCLUSIONS

A working model aiming to ameliorate child poverty in a societal service context needs to address the preconceptions and perceived mandate and role of the professionals, the prevalence of financial stigma in society, especially in relation to being a 'good' parent, and the current preoccupations and perceived financial needs and hopes of the families served.

Association of social determinants of health-related diagnosis codes with postoperative outcomes

BACKGROUND

The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes.

METHODS

This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes.

RESULTS

Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73).

CONCLUSIONS

Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.

Closing the Loop: Enhancing Local Monitoring of Child Poverty to Leave No Child Behind

Research on the Leave No One Behind principle of the Sustainable Development Goals (SDGs) within the context of the Agenda 2030 is currently prevalent; however, research on monitoring child poverty at the sub-national (local) level is still limited. This paper addresses this gap by examining indicators developed for monitoring the phenomenon at different territorial levels (global, European, and national) and assessing their territorial transposition locally, using the city of Cadiz, Spain, as a case study. Interviews with local stakeholders reveal that despite the availability and access to related indicators and data, relevant actors must enhance their efforts to utilize such indicators effectively. Based on desktop research and qualitative analysis, the paper delivers recommendations for improving local monitoring of child poverty in Europe and inducing policy changes. This knowledge can inform targeted interventions, policy formulation, and resource allocation to tackle child poverty and promote equitable and inclusive societies.

Cumulative Health Vulnerabilities Among Adolescents by Age and Neighborhood Opportunity

BACKGROUND AND OBJECTIVES

Early detection of health vulnerabilities in adolescents is integral to promoting healthy behaviors into adulthood. Our objective was to quantify the prevalence of health vulnerabilities among adolescents and examine differences by age and neighborhood opportunity.

METHODS

In a cross-sectional analysis of electronic health record data for adolescents aged 13 to 18 years with preventive visits in a large pediatric primary care network between September 2021 and September 2022, we examined 5 health vulnerabilities: Tobacco use, substance use, firearm access, condomless intercourse, and depressive symptoms. Health vulnerabilities were assessed via self-reported adolescent health questionnaire and the validated Patient Health Questionnaire-Modified. Prevalence of health vulnerabilities were calculated alone and in combination, and compared by age and by quintile of neighborhood Child Opportunity Index (COI) score. Multivariable logistic regression estimated associations of neighborhood COI with reporting ≥2 health vulnerabilities.

RESULTS

Among 40 197 adolescents (57.7% aged 13-15 years, 66.3% living in "high"/"very high" COI neighborhoods), 29.7% reported at least 1 health vulnerability and 7.9% reported ≥2 vulnerabilities. Cumulative health vulnerabilities were more prevalent among older adolescents and adolescents from lower opportunity neighborhoods. In adjusted models, lower COI was associated with 65% higher odds of having ≥2 vulnerabilities (odds ratio 1.65, 95% confidence interval 1.43-1.91) compared with adolescents from the highest COI quintile.

CONCLUSIONS

Understanding the relationship between health vulnerabilities and neighborhood opportunities among adolescents may allow pediatric primary care providers and health systems to offer more tailored community support services and transdiagnostic specialized care navigation to address the health needs of teens with multiple vulnerabilities.

Association of Neighborhood Environment with the Outcomes of Childhood Glaucoma

PURPOSE

To determine the association between different neighborhood environment factors and the outcomes of childhood glaucoma.

DESIGN

A retrospective cohort.

PARTICIPANTS

Childhood glaucoma patients ≤ 18 years of age at the time of diagnosis.

METHODS

A retrospective chart review of childhood glaucoma patients who presented to Boston Children's Hospital between 2014 and 2019. Data collected included etiology, intraocular pressure (IOP), management, and visual outcomes. Child Opportunity Index (COI) was used as a metric of neighborhood quality.

MAIN OUTCOMES MEASURES

The association of visual acuity (VA) and IOP with COI scores using linear mixed-effect models, adjusting for individual demographics.

RESULTS

A total of 221 eyes (149 patients) were included. Of these, 54.36% were male and 56.4% were non-Hispanic Whites. The median age at the time of presentation was 5 months for primary glaucoma and 5 years for secondary glaucoma. The median age at the last follow-up was 6 and 13 years for primary and secondary glaucoma, respectively. A chi-square test revealed that the COI, health and environment, social and economic, and education indexes between primary and secondary glaucoma patients were comparable. For primary glaucoma, the overall COI and a higher education index were associated with a lower final IOP (P < 0.05), and higher education index was associated with a lower number of glaucoma medications at the last follow-up (P < 0.05). For secondary glaucoma, higher overall COI, health and environment, social and economic, and education indices were associated with better final VA (lower logarithms of the minimum angle of resolution VA) (P < 0.001).

CONCLUSIONS

Neighborhood environment quality is a potentially important variable for predicting outcomes in childhood glaucoma. Lower COI scores were associated with worse outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of Childhood and Midlife Neighborhood Socioeconomic Position With Cognitive Decline

Importance

Early-life socioeconomic adversity may be associated with poor cognitive health over the life course.

Objective

To examine the association of childhood and midlife neighborhood socioeconomic position (nSEP) with cognitive decline.

Design, Setting, and Participants

This cohort study included 5711 men and women enrolled in the community-based Atherosclerosis Risk in Communities (ARIC) Study with repeated cognitive data measured over a median 27.0 years (IQR, 26.0-27.9 years) (1990-2019). Statistical analysis was performed from December 2022 through March 2023.

Exposure

Residence addresses for ARIC Study cohort participants were obtained at midlife (1990-1993) and as recalled addresses at 10 years of age (childhood). A composite nSEP z score was created as a sum of z scores for US Census-based measures of median household income; median value of owner-occupied housing units; percentage of households receiving interest, dividend, or net rental income; percentage of adults with a high school degree; percentage of adults with a college degree; and percentage of adults in professional, managerial, or executive occupations. Childhood nSEP and midlife nSEP were modeled as continuous measures and discretized into tertiles.

Main Outcomes and Measures

A factor score for global cognition was derived from a battery of cognitive tests administered at 5 in-person visits from baseline to 2019. The rate of cognitive decline from 50 to 90 years of age was calculated by fitting mixed-effects linear regression models with age as the time scale and adjusted for race, sex, birth decade, educational level, and presence of the apolipoprotein E ε4 allele.

Results

Among 5711 ARIC Study participants (mean [SD] baseline age, 55.1 [4.7] years; 3372 women [59.0%]; and 1313 Black participants [23.0%]), the median rate of cognitive decline was -0.33 SDs (IQR, -0.49 to -0.20 SDs) per decade. In adjusted analyses, each 1-SD-higher childhood nSEP score was associated with a slower (β, -9.2%; 95% CI, -12.1% to -6.4%) rate of cognitive decline relative to the sample median. A comparable association was observed when comparing the highest tertile with the lowest tertile of childhood nSEP (β, -17.7%; 95% CI, -24.1% to -11.3%). Midlife nSEP was not associated with the rate of cognitive decline.

Conclusions and Relevance

In this cohort study of contextual factors associated with cognitive decline, childhood nSEP was inversely associated with trajectories of cognitive function throughout adulthood.

Segregated by Wealth, Health, and Development: An Analysis of Pre-School Child Health in a Medium-Sized German City

The School Entry Examination (SEE) can be used to identify children with current health issues, developmental delays, and risk factors for later diseases. This study analyzes the health status of preschool children in a German city with considerable socio-economic differences among its quarters. We used secondary data from SEEs 2016-2019 from the entire city (8417 children), which we divided into quarters with low (LSEB), medium (MSEB), and high socioeconomic burden (HSEB). In HSEB quarters, 11.3% of children were overweight as opposed to 5.3% in LSEB quarters. In HSEB quarters, 17.2% of children had sub-par cognitive development in contrast to 1.5% in LSEB quarters. For overall sub-par development, LSEB quarters had a prevalence of 3.3%, whereas, in HSEB quarters, 35.8% of children received this result. Logistic regression was used to determine the influence of the city quarter on the outcome of overall sub-par development. Here, considerable disparities among HSEB and LSEB quarters remained after adjustment for parents' employment status and education. Pre-school children in HSEB quarters showed a higher risk for later disease than children in LSEB quarters. The city quarter had an association with child health and development that should be considered in the formulation of interventions.

Child Opportunity Index and Emergent PICU Readmissions: A Retrospective, Cross-Sectional Study of 43 U.S. Hospitals

OBJECTIVES

To examine the association between a validated composite measure of neighborhood factors, the Child Opportunity Index (COI), and emergent PICU readmission during the year following discharge for survivors of pediatric critical illness.

DESIGN

Retrospective cross-sectional study.

SETTING

Forty-three U.S. children's hospitals contributing to the Pediatric Health Information System administrative dataset.

PATIENTS

Children (< 18 yr) with at least one emergent PICU admission in 2018-2019 who survived an index admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 78,839 patients, 26% resided in very low COI neighborhoods, 21% in low COI, 19% in moderate COI, 17% in high COI, and 17% in very high COI neighborhoods, and 12.6% had an emergent PICU readmission within 1 year. After adjusting for patient-level demographic and clinical factors, residence in neighborhoods with moderate, low, and very low COI was associated with increased odds of emergent 1-year PICU readmission relative to patients in very high COI neighborhoods. Lower COI levels were associated with readmission in diabetic ketoacidosis and asthma. We failed to find an association between COI and emergent PICU readmission in patients with an index PICU admission diagnosis of respiratory conditions, sepsis, or trauma.

CONCLUSIONS

Children living in neighborhoods with lower child opportunity had an increased risk of emergent 1-year readmission to the PICU, particularly children with chronic conditions such as asthma and diabetes. Assessing the neighborhood context to which children return following critical illness may inform community-level initiatives to foster recovery and reduce the risk of adverse outcomes.

The GROWBABY Research Network: A Framework for Advancing Health Equity Through Community Engaged Practice-Based Research

PURPOSE

Preventive health care, delivered through well child care visits, serves as a universal and primary entry point for promoting child wellbeing, yet children with lower socioeconomic status and children of color receive less consistent and lower quality preventive health care. Currently, limited research exists comparing models for delivering preventive care to children and their impact on longstanding racial/ethnic and socioeconomic inequities.

DESCRIPTION

Practice-based research networks can help to advance health equity by more rapidly studying and scaling innovative, local models of care to reduce racial/ethnic and socioeconomic inequities in primary care and preventive care utilization. This paper outlines a framework of community engagement that can be utilized by practice-based research networks to advance health equity and details the application of the framework using the GROWBABY Research Network (GROup Wellness Visits for BABies and FamilY Research Network).

ASSESSMENT

The GROWBABY Research Network launched in 2020, engaged clinical practices utilizing this unique model of group well childcare - CenteringParenting® - with the following goals: to promote collaboration among researchers, clinicians, patients, and community members; facilitate practice-based research; and increase the use of shared assessment measures and protocols. As a research collaborative, the GROWBABY Research Network connects clinical partners facing similar challenges and creates opportunities to draw upon the assets and strengths of the collective to identify solutions to the barriers to research participation.

CONCLUSION

Primary care, practice-based research networks like the GROWBABY Research Network that intentionally integrate community engagement principles and community-based participatory research methods can advance equitable health care systems and improve child wellbeing.

Are Neighborhood Conditions Associated With Surgical Delays and Meniscus Tears in Children and Adolescents Undergoing ACL Reconstruction?

BACKGROUND

Markers of a patient's social determinants of health, including healthcare insurance and median household income based on ZIP Code, have been associated with the interval between injury and ACL reconstruction (ACLR) as well as the presence of concomitant meniscus tears in children and adolescents. However, the aforementioned surrogate indicators of a patient's social determinants of health may not reflect all socioeconomic and healthcare resources affecting the care of ACL injuries in children and adolescents. The use of multivariate indices such as the Child Opportunity Index (COI) may help to better identify patients at risk for increased risk for delay between ACL injury and surgery, as well as the incidence of meniscus tears at the time of surgery. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic factors. COI scores range from 0 to 100 (100 being the highest possible score), as well as five categorical scores (very low, low, moderate, high, and very high) based on quintile rankings.

QUESTIONS/PURPOSES

To investigate the relationship between neighborhood conditions and the treatment of ACL injuries in children and adolescents via the COI, we asked: (1) Is a lower COI score associated with a longer delay between ACL injury and surgery? (2) Does a higher proportion of patients with lower COI scores have meniscus tears at the time of ACLR?

METHODS

In this retrospective, comparative study, we considered data from 565 patients, 18 years or younger, who underwent primary ACLR at an urban, tertiary children's hospital between 2011 and 2021. Of these patients, 5% (31 of 565) did not have a clearly documented date of injury, 2% (11 of 565) underwent revision reconstructions, and 1% (5 of 565) underwent intentionally delayed or staged procedures. Because we specifically sought to compare patients who had low or very low COI scores (lowest two quintiles) with those who had high or very high scores (highest two quintiles), we excluded 18% (103 of 565) of patients with moderate scores. Ultimately, 73% (415 of 565) of patients with COI scores in either the top or bottom two quintiles were included. Patient addresses at the time of surgery were used to determine the COI score. There were no differences between the groups in terms of gender. However, patients with high or very high COI scores had a lower median (IQR) age (15 years [2.6] versus 17 years [1.8]; p < 0.001) and BMI (23 kg/m 2 [6.1] versus 25 kg/m 2 [8.8]; p < 0.001), were more commonly privately insured (62% [117 of 188] versus 22% [51 of 227]; p < 0.001), and had a higher proportion of patients identifying as White (67% [126 of 188] versus 6.2% [14 of 227]; p < 0.001) compared with patients with low or very low COI scores. Medical records were reviewed for demographic, preoperative, and intraoperative data. Univariate analyses focused on the relationship of the COI and interval between injury and surgery, frequency of concomitant meniscus tears, and frequency of irreparable meniscus tears treated with partial meniscectomy. Multivariable regression analyses were used to determine factors that were independently associated with delayed surgery (longer than 60 and 90 days after injury), presence of concomitant meniscal injuries, and performance of meniscectomy. Multivariable models included insurance and race or ethnicity to determine whether COI was independently associative after accounting for these variables.

RESULTS

Patients with a high or very high COI score had surgery earlier than those with a low or very low COI score (median [IQR] 53 days [53] versus 97 days [104]; p < 0.001). After adjusting for insurance and race/ethnicity, we found that patients with a low or very low COI score were more likely than patients with a high or very high COI score to have surgery more than 60 days after injury (OR 2.1 [95% CI 1.1 to 4.0]; p = 0.02) or more than 90 days after injury (OR 1.8 [95% CI 1.1 to 3.4]; p = 0.04). Furthermore, patients with low or very low COI scores were more likely to have concomitant meniscus tears (OR 1.6 [95% CI 1.1 to 2.5]; p = 0.04) compared with patients with high or very high COI scores. After controlling for insurance, race/ethnicity, time to surgery, and other variables, there was no association between COI and meniscectomy (OR 1.6 [95% CI 0.9 to 2.8]; p = 0.12) or presence of a chondral injury (OR 1.7 [95% CI 0.7 to 3.9]; p = 0.20).

CONCLUSION

As the COI score is independently associated with a delay between ACL injury and surgery as well as the incidence of meniscus tears at the time of surgery, this score can be useful in identifying patients and communities at risk for disparate care after ACL injury. The COI score or similar metrics can be incorporated into medical records to identify at-risk patients and dedicate appropriate resources for efficient care. Additionally, neighborhoods with a low COI score may benefit from improvements in the availability of additional and/or improved resources. Future studies should focus on the relationship between the COI score and long-term patient-reported functional outcomes after ACL injury, identification of the specific timepoints in care that lead to delayed surgery for those with lower COI scores, and the impact of community-based interventions in improving health equity in children with ACL injury.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Impact of COVID-19 Related Maternal Stress on Fetal Brain Development: A Multimodal MRI Study

BACKGROUND

Disruptions in perinatal care and support due to the COVID-19 pandemic was an unprecedented but significant stressor among pregnant women. Various neurostructural differences have been re-ported among fetuses and infants born during the pandemic compared to pre-pandemic counterparts. The relationship between maternal stress due to pandemic related disruptions and fetal brain is yet unexamined.

METHODS

Pregnant participants with healthy pregnancies were prospectively recruited in 2020-2022 in the greater Los Angeles Area. Participants completed multiple self-report assessments for experiences of pandemic related disruptions, perceived stress, and coping behaviors and underwent fetal MRI. Maternal perceived stress exposures were correlated with quantitative multimodal MRI measures of fetal brain development using multivariate models.

RESULTS

Increased maternal perception of pandemic related stress positively correlated with normalized fetal brainstem volume (suggesting accelerated brainstem maturation). In contrast, increased maternal perception of pandemic related stress correlated with reduced global fetal brain temporal functional variance (suggesting reduced functional connectivity).

CONCLUSIONS

We report alterations in fetal brainstem structure and global functional fetal brain activity associated with increased maternal stress due to pandemic related disruptions, suggesting altered fetal programming. Long term follow-up studies are required to better understand the sequalae of these early multi-modal brain disruptions among infants born during the COVID-19 pandemic.

Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index

OBJECTIVE

To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI).

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics.

RESULTS

There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models.

CONCLUSIONS

Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hospital-Level Neighborhood Opportunity and Rehospitalization for Common Diagnoses at US Children's Hospitals

OBJECTIVE

Neighborhood conditions influence child health outcomes, but data examining association between local factors and hospital utilization are lacking. We determined if hospitals' mix of patients by neighborhood opportunity correlates with rehospitalization for common diagnoses at US children's hospitals.

METHODS

We analyzed all discharges in 2018 for children ≤18 years at 47 children's hospitals for 14 common diagnoses. The exposure was hospital-level mean neighborhood opportunity - measured by Child Opportunity Index (COI) - for each diagnosis. The outcome was same-cause rehospitalization within 365 days. We measured association via Pearson correlation coefficient. For diagnoses with significant associations, we also examined shorter rehospitalization time windows and compared unadjusted and COI-adjusted rehospitalization rates.

RESULTS

There were 256,871 discharges included. Hospital-level COI ranged from 17th to 70th percentile nationally. Hospitals serving lower COI neighborhoods had more frequent rehospitalization for asthma (ρ -0.34 [95% confidence interval -0.57, -0.06]) and diabetes (ρ -0.33 [-0.56, -0.04]), but fewer primary mental health rehospitalizations (ρ 0.47 [0.21, 0.67]). There was no association for 11 other diagnoses. Secondary timepoint analysis revealed increasing correlation over time, with differences by diagnosis. Adjustment for hospital-level COI resulted in 26%, 32%, and 45% of hospitals changing >1 decile in rehospitalization rank order for diabetes, asthma, and mental health diagnoses, respectively.

CONCLUSIONS

Children's hospitals vary widely in their mix of neighborhoods served. Asthma, diabetes, and mental health rehospitalization rates correlate with COI, suggesting that neighborhood factors may influence outcome disparities for these conditions. Hospital outcomes may be affected by neighborhood opportunity, which has implications for benchmarking.

Impact of COVID-19 related maternal stress on fetal brain development: A Multimodal MRI study

Background

Disruptions in perinatal care and support due to the COVID-19 pandemic was an unprecedented but significant stressor among pregnant women. Various neurostructural differences have been re-ported among fetuses and infants born during the pandemic compared to pre-pandemic counterparts. The relationship between maternal stress due to pandemic related disruptions and fetal brain is yet unexamined.

Methods

Pregnant participants with healthy pregnancies were prospectively recruited in 2020-2022 in the greater Los Angeles Area. Participants completed multiple self-report assessments for experiences of pandemic related disruptions, perceived stress, and coping behaviors and underwent fetal MRI. Maternal perceived stress exposures were correlated with quantitative multimodal MRI measures of fetal brain development using ltivariate models.

Results

Fetal brain stem volume increased with increased maternal perception of pandemic related stress positively correlated with normalized fetal brainstem volume (suggesting accelerated brainstem maturation). In contrast, increased maternal perception of pandemic related stress correlated with reduced global fetal brain temporal functional variance (suggesting reduced functional connectivity).

Conclusions

We report alterations in fetal brainstem structure and global functional fetal brain activity associated with increased maternal stress due to pandemic related disruptions, suggesting altered fetal programming. Long term follow-up studies are required to better understand the sequalae of these early multi-modal brain disruptions among infants born during the COVID-19 pandemic.

Contemporary Socioeconomic and Childhood Opportunity Disparities in Congenital Heart Surgery

BACKGROUND

While singular measures of socioeconomic status have been associated with outcomes after surgery for congenital heart disease, the multifaceted pathways through which a child's environment impacts similar outcomes remain incompletely characterized. We sought to evaluate the association between childhood opportunity level and adverse outcomes after congenital heart surgery.

METHODS

Data from patients undergoing congenital cardiac surgery from January 2011 to January 2020 at a quaternary referral center were retrospectively reviewed. Outcomes of interest included predischarge (early) mortality or transplant, postoperative hospital length-of-stay, inpatient cost of hospitalization, postdischarge (late) mortality or transplant, and late unplanned reintervention. The primary predictor was a US census tract-based, nationally-normed composite metric of contemporary child neighborhood opportunity comprising 29 indicators across 3 domains (education, health and environment, and socioeconomic), categorized as very low, low, moderate, high, and very high. Associations between childhood opportunity level and outcomes were evaluated using logistic regression (early mortality), generalized linear (length-of-stay and cost), Cox proportional hazards (late mortality), or competing risk (late reintervention) models, adjusting for baseline patient-related factors, case complexity, and residual lesion severity.

RESULTS

Of 6133 patients meeting entry criteria, the median age was 2.0 years (interquartile range, 3.6 months-8.3 years). There were 124 (2.0%) early deaths or transplants, the median postoperative length-of-stay was 7 days (interquartile range, 5-13 days), and the median inpatient cost was $76 000 (interquartile range, $50 000-130 000). No significant association between childhood opportunity level and early mortality or transplant was observed (P=0.21). On multivariable analysis, children with very low and low opportunity had significantly longer length-of-stay and incurred higher costs compared with those with very high opportunity (all P<0.05). Of 6009 transplant-free survivors of hospital discharge, there were 175 (2.9%) late deaths or transplants, and 1008 (16.8%) reinterventions at up to 10.5 years of follow-up. Patients with very low opportunity had a significantly greater adjusted risk of late death or transplant (hazard ratio, 1.7 [95% CI, 1.1-2.6]; P=0.030) and reintervention (subdistribution hazard ratio, 1.9 [95% CI, 1.5-2.3]; P<0.001), versus those with very high opportunity.

CONCLUSIONS

Childhood opportunity level is independently associated with adverse outcomes after congenital heart surgery. Children from resource-limited settings thus constitute an especially high-risk cohort that warrants closer surveillance and tailored interventions.

Influence of Parent–Child Conflict on Psychological Distress among Chinese Adolescents: Moderating Effects of School Connectedness and Neighborhood Disorder

Previous empirical studies have found that not all adolescents showed a high level of psychological distress when facing parent–child conflict, which implies that there could be some additional moderating variables in this pair association. School connectedness and neighborhood disorder have been regarded as possible moderators of this relationship, but empirical evidence is lacking. The participants in this study included 971 students from two middle schools (grades 7–9) and two high schools (grades 10–12) and their parents in the City of Y, Shanxi Province, in mainland China. The PROCESS macro was used to conduct the moderation analysis. The results revealed that both school connectedness and neighborhood disorder significantly moderated the association of parent–child conflict with adolescent psychological distress. These findings highlighted the significance of increasing school connectedness and decreasing neighborhood disorder to alleviate adolescent psychological distress, thereby contributing to related policies and interventions.

Poverty after Birth: How Mothers Experience and Navigate U.S. Safety Net Programs to Address Family Needs

Although pregnancy and the first year of life are sensitive windows for child development, we know very little about the lived experiences of mothers living in poverty or near poverty during the perinatal period; specifically, how they perceive and use public resources to support themselves and their newborn. In this qualitative study, we explore how predominantly Black and Latinx mothers with infants living in or near poverty and engaged in public assistance manage to meet their family's needs with available resources from safety net programs and social supports. We conducted 20 qualitative interviews with mothers living in (85%) or near poverty in New York City (NYC). All participants (mean age = 24) had an 11-month-old infant at the time of the interview. Using thematic analysis, we identified five main themes reflecting how mothers experience and navigate living with very low incomes while engaging in public assistance programs: (1) experiencing cascading effects of hardships during pregnancy, (2) relying on food assistance and informal supports amid scarcity, (3) waiting for limited affordable housing: 'life on hold', (4) finding pathways towards stability after the baby's birth, (5) making it work: efforts to look forward. Results describe how the current focus on "work first" of existing federal and state policies adds a layer of stress and burden on the lives of single mothers experiencing low incomes and entangled hardships during pregnancy and after birth. We document how mothers experience coverage gaps and implementation challenges navigating the patchwork of public assistance programs, yet how the support of flexible caseworkers accessing, using, and coordinating assistance has the potential to help mothers plan for longer-term goals.

Differences in Outpatient Health Care Utilization 12 Months after COVID-19 Infection by Race/Ethnicity and Community Social Vulnerability

Ensuring access to high-quality outpatient care is an important strategy to improve COVID-19 outcomes, reduce social inequities, and prevent potentially expensive complications of disease. This study assesses the equity of health care response to COVID-19 by examining outpatient care utilization by factors at the individual and community levels in the 12 months prior to and following COVID-19 diagnosis. Employing a retrospective, observational cohort design, we analyzed electronic health record data from a sample of 11,326 adults diagnosed with COVID-19 between March and July 2020. We used two-part models to estimate changes in use of primary and specialty care by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our findings showed that while overall probability and counts of primary and specialty care visits increased following a positive COVID-19 diagnosis, disparities in care utilization by race/ethnicity and living in a socially vulnerable community persisted in the year that followed. These findings reiterate the need for strategic approaches to improve access to and utilization of care among those diagnosed with COVID-19, especially for individuals who are traditionally undeserved by the health system. Our findings also highlight the importance of systematic approaches for addressing social inequity in health care.

The Child Opportunity Index 2.0 and Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND AND OBJECTIVES

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are thought to be avoidable with high-quality outpatient care. Morbidity related to ACSCs has been associated with socioeconomic contextual factors, which do not necessarily capture the complex pathways through which a child's environment impacts health outcomes. Our primary objective was to test the association between a multidimensional measure of neighborhood-level child opportunity and pediatric hospitalization rates for ACSCs across 2 metropolitan areas.

METHODS

This was a retrospective population-based analysis of ACSC hospitalizations within the Kansas City and Cincinnati metropolitan areas from 2013 to 2018. Census tracts were included if located in a county where Children's Mercy Kansas City or Cincinnati Children's Hospital Medical Center had >80% market share of hospitalizations for children <18 years. Our predictor was child opportunity as defined by a composite index, the Child Opportunity Index 2.0. Our outcome was hospitalization rates for 8 ACSCs.

RESULTS

We included 604 943 children within 628 census tracts. There were 26 977 total ACSC hospitalizations (46 hospitalizations per 1000 children; 95% confidence interval [CI]: 45.4-46.5). The hospitalization rate for all ACSCs revealed a stepwise reduction from 79.9 per 1000 children (95% CI: 78.1-81.7) in very low opportunity tracts to 31.2 per 1000 children (95% CI: 30.5-32.0) in very high opportunity tracts (P < .001). This trend was observed across cities and diagnoses.

CONCLUSIONS

Links between ACSC hospitalizations and child opportunity extend across metropolitan areas. Targeting interventions to lower-opportunity neighborhoods and enacting policies that equitably bolster opportunity may improve child health outcomes, reduce inequities, and decrease health care costs.

Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States

OBJECTIVE

To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US.

STUDY DESIGN

This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics.

RESULTS

In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81).

CONCLUSIONS

Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.

Community Engagement Practices at Research Centers in U.S. Minority Institutions: Priority Populations and Innovative Approaches to Advancing Health Disparities Research

This paper details U.S. Research Centers in Minority Institutions (RCMI) Community Engagement Cores (CECs): (1) unique and cross-cutting components, focus areas, specific aims, and target populations; and (2) approaches utilized to build or sustain trust towards community participation in research. A mixed-method data collection approach was employed for this cross-sectional study of current or previously funded RCMIs. A total of 18 of the 25 institutions spanning 13 U.S. states and territories participated. CEC specific aims were to support community engaged research (94%); to translate and disseminate research findings (88%); to develop partnerships (82%); and to build capacity around community research (71%). Four open-ended questions, qualitative analysis, and comparison of the categories led to the emergence of two supporting themes: (1) establishing trust between the community-academic collaborators and within the community and (2) building collaborative relationships. An overarching theme, building community together through trust and meaningful collaborations, emerged from the supporting themes and subthemes. The RCMI institutions and their CECs serve as models to circumvent the historical and current challenges to research in communities disproportionately affected by health disparities. Lessons learned from these cores may help other institutions who want to build community trust in and capacities for research that addresses community-related health concerns.

Neighborhood-Level Lead Paint Hazard for Children under 6: A Tool for Proactive and Equitable Intervention

Lead is well known for its adverse health effects on children, particularly when exposure occurs at earlier ages. The primary source of lead hazards among young children is paint used in buildings built before 1978. Despite being 100% preventable, some children remain exposed and state and local policies often remain reactive. This study presents a methodology for planners and public health practitioners to proactively address lead risks among young children. Using geospatial analyses, this study examines neighborhood level measurement of lead paint hazard in homes and childcare facilities and the concentration of children aged 0–5. Results highlight areas of potential lead paint hazard hotspots within a county in the Midwestern state studied, which coincides with higher concentration of non-white children. This places lead paint hazard in the context of social determinants of health, where existing disparity in distribution of social and economic resources reinforces health inequity. In addition to being proactive, lead poisoning intervention efforts need to be multi-dimensional and coordinated among multiple parties involved. Identifying children in higher lead paint hazard areas, screening and treating them, and repairing their homes and childcare facilities will require close collaboration of healthcare professionals, local housing and planning authorities, and community members.

Understanding sleep facilitators, barriers, and cultural dimensions in Native American urban youth

OBJECTIVES

American Indian/Alaska Native (AI/AN) youth are a high-risk group for sleep problems and associated chronic conditions. Urban AI/AN youth may face certain challenges, including specific psychosocial stressors (e.g., discrimination) and environmental factors (e.g., noise, light) that render them particularly vulnerable to poor sleep health. However, few studies have explored AI/AN adolescent sleep. To our knowledge, this is the first study to use systematic qualitative methods with AI/AN youth to explore their sleep environment and sleep behaviors.

DESIGN

In-depth interviews with 26 youth.

SETTING

Two urban areas in Central and Southern California.

PARTICIPANTS

Urban-dwelling AI/AN youth, age 12-16 years.

INTERVENTION

N/A.

MEASUREMENT

N/A.

RESULTS

We identified five main themes, each with subthemes: sleep patterns and desired sleep, sleep barriers inside the home, environmental factors, sleep facilitators, and cultural dimensions. Key concerns discussed were poor sleep hygiene, excessive use of electronics prior to bedtime, issues with temperature regulation, and noise both within and outside the home. Parents can be an important vehicle for messaging around sleep health and for behavior management. Participating adolescents also indicated differing levels of attachment to Native identity, suggesting that culturally-targeted sleep interventions should build in openness and flexibility to a range of identity starting points. Further, we identified cultural practices, such as sweat lodges and dreamcatchers, that could be incorporated in future sleep interventions for this population.

CONCLUSION

Findings increase our understanding of urban AI/AN youth's sleep environments and behaviors, thus potentially informing program development around sleep health for this vulnerable population.

Neighborhood disorder and child behavioral problems among kinship children: Mediated by social support and moderated by race/ethnicity?

BACKGROUND

Children in kinship care may be placed in similar neighborhoods as their birth families, which are predominantly characterized as distressed neighborhoods with high poverty and crime rates, poor-quality housing conditions, and few social resources. Disordered neighborhoods are negatively correlated to social support, but this dynamic may vary by race or ethnicity. However, children's previously established attachment and social bonding may offset the negative effects of distressed neighborhoods on child behavioral health.

OBJECTIVES

This study examined the relation between neighborhood disorder and children's internalizing and externalizing problems among children in kinship care and tested caregivers' social support as a potential mediator. Moreover, this study examined if race/ethnicity moderated the pathway from neighborhood disorder to social support, and from social support to children's internalizing and externalizing problems.

PARTICIPANTS AND SETTING

This study used NSCAW II wave 3 data for a sample of children in kinship care.

METHODS

Univariate, bivariate, and moderated mediation analyses were conducted using STATA 15.

RESULTS

Neighborhood disorder was indirectly associated with children's internalizing and externalizing problems through a mediator of social support. No racial/ethnic differences were identified.

CONCLUSIONS

Implications for improving social support for kinship caregivers to ameliorate the effects of neighborhood disorder on children's behavioral health are discussed. Implementing effective neighborhood-level interventions could promote positive outcomes for children in kinship care.

The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.

Cross-sectional analysis of place-based and racial disparities in hospitalisation rates by disease category in California in 2001 and 2011

OBJECTIVES

To study the association of place-based socioeconomic factors with disease distribution by comparing hospitalisation rates in California in 2001 and 2011 by zip code median household income.

DESIGN

Serial cross-sectional study testing the association between hospitalisation rates and zip code-level median income, with subgroup analyses by zip code income and race.

PARTICIPANTS/SETTING

Our study included all hospitalised adults over 18 years old living in California in 2001 and 2011 who were not pregnant or incarcerated. This included all acute-care hospitalisations in California including 1632 zip codes in 2001 and 1672 zip codes in 2011.

PRIMARY AND SECONDARY OUTCOMES

We compared age-standardised hospitalisations per 100 000 persons, overall and for several disease categories.

RESULTS

There were 1.58 and 1.78 million hospitalisations in California in 2001 and 2011, respectively. Spatial analysis showed the highest hospitalisation rates in urban inner cities and rural areas, with more than 5000 hospitalisations per 100 000 persons. Hospitalisations per 100 000 persons were consistently highest in the lowest zip code income quintile and particularly among black patients.

CONCLUSION

Hospitalisation rates rose from 2001 to 2011 among Californians living in low-income and middle-income zip codes. Integrating spatially defined state hospital discharge and federal zip code income data provided a granular description of disease burden. This method may help identify high-risk areas and evaluate public health interventions targeting health disparities.

Prenatal air pollution and childhood IQ: Preliminary evidence of effect modification by folate

OBJECTIVES

Animal studies suggest that air pollution is neurotoxic to a developing fetus, but evidence in humans is limited. We tested the hypothesis that higher air pollution is associated with lower child IQ and that effects vary by maternal and child characteristics, including prenatal nutrition.

METHODS

We used prospective data collected from the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study. Outdoor pollutant exposure during pregnancy was predicted at geocoded home addresses using a validated national universal kriging model that combines ground-based monitoring data with an extensive database of land-use covariates. Distance to nearest major roadway was also used as a proxy for traffic-related pollution. Our primary outcome was full-scale IQ measured at age 4-6. In regression models, we adjusted for multiple determinants of child neurodevelopment and assessed interactions between air pollutants and child sex, race, socioeconomic status, reported nutrition, and maternal plasma folate in second trimester.

RESULTS

In our analytic sample (N = 1005) full-scale IQ averaged 2.5 points (95% CI: 0.1, 4.8) lower per 5 μg/m³ higher prenatal PM₁₀, while no associations with nitrogen dioxide or road proximity were observed. Associations between PM₁₀ and IQ were modified by maternal plasma folate (p_interaction = 0.07). In the lowest folate quartile, IQ decreased 6.8 points (95% CI: 1.4, 12.3) per 5-unit increase in PM₁₀; no associations were observed in higher quartiles.

CONCLUSIONS

Our findings strengthen evidence that air pollution impairs fetal neurodevelopment and suggest a potentially important role of maternal folate in modifying these effects.

Associations Between Environmental Conditions and Executive Cognitive Functioning and Behavior During Late Childhood: A Pilot Study

Numerous studies have established the influence of detrimental home conditions on child cognition and behavior; however, fewer have assessed these outcomes in the context of relatively "normal" range of home environmental conditions. Given the exquisite sensitivity to the environment of the neural substrates that undergird executive functioning (EF) and behavioral self-regulation in children, it is possible that a range of conditions within the home, even in the absence of maltreatment or economic deprivation, may impact these outcomes. The purpose of the present exploratory investigation was to further define the relationship between features of the home environment using the HOME inventory (a structured interview and observation of parent and child) and several dimensions of child EF and behavioral problems. In addition, this study sought to elucidate potentially differential associations between home and parent-reported neighborhood conditions-a hypothetically less direct influence on cognition in this age group-and level of child functioning. A battery of EF performance tasks and a widely-used checklist of behavioral problems were administered to 66 children, 8-11 years old from a lower middle income, working class sample. Results showed significant relationships between the home environment and several dimensions of EF and behavioral problems. In contrast, neighborhood conferred additional effects only on rule-breaking and aggression, not cognition, which is consistent with evidence that externalizing behavior in this age group becomes increasingly oriented toward outside influences. These findings warrant follow-up studies to establish causality. A broader program of research designed to delve further into the relationship between nuanced influences from the home and child cognition and behavior has implications for parenting strategies that foster healthy development. Neighborhood contexts should also be considered during early and mid-adolescent years based on existing studies and findings reported herein suggesting that this period of newfound autonomy and the heightened significance of peer relationships may influence externalizing behaviors, with implications for protective courses of action.

Mapping Neighborhood Health Geomarkers To Clinical Care Decisions To Promote Equity In Child Health

Health disparities, which can be understood as disadvantages in health associated with one's social, racial, economic, or physical environment, originate in childhood and persist across an individual's life course. One's neighborhood may drive or influence these disparities. Information on neighborhoods that can characterize their risks-what we call place-based risks-is rarely used in patient care. Community-level data, however, could inform and personalize interventions such as arranging for mold removal from the home of a person with asthma from the moment that person's address is recorded at the site of care. Efficient risk identification could lead to the tailoring of recommendations and targeting of resources, to improve care experiences and clinical outcomes while reducing disparities and costs. In this article we highlight how data on place-based social determinants of health from national and local sources could be incorporated more directly into patient-centered care, adding precision to risk assessment and mitigation. We also discuss how this information could stimulate cross-sector interventions that promote health equity: the attainment of the highest level of health for neighborhoods, patient panels, and individuals. Finally, we draw attention to research questions that focus on the role of geographical place at the bedside.

Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses

: media-1vid110.1542/5751513300001PEDS-VA_2017-2309Video Abstract OBJECTIVES: Although health care providers and systems are increasingly interested in patients' nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses.

METHODS

This cross-sectional study included San Francisco residents <18 years of age with an emergency department and/or urgent care visit to any of 3 medical systems (N = 47 175) between 2007 and 2011. Hot-spot analysis was used to compare the spatial distribution of neighborhood child opportunity and income. Generalized estimating equation logistic regression models were used to examine independent associations between neighborhood child opportunity and frequent acute care use (≥4 visits per year) and diagnosis group after adjusting for neighborhood income and patient age, sex, race and/or ethnicity, payer, and health system.

RESULTS

Neighborhood child opportunity and income had distinct spatial distributions, and we identified different clusters of high- and low-risk neighborhoods. Children living in the lowest opportunity neighborhoods had significantly greater odds of ≥4 acute care visits per year (odds ratio 1.33; 95% confidence interval 1.03-1.73) compared with those in the highest opportunity neighborhoods. Neighborhood child opportunity was negatively associated with visits for respiratory conditions, asthma, assault, and ambulatory care-sensitive conditions but positively associated with injury-related visits.

CONCLUSIONS

The Child Opportunity Index could be an effective tool for identifying neighborhood factors beyond income related to child health.

A Prospective Study of the Impact of Current Poverty, History of Poverty, and Exiting Poverty on Accumulation of Disease Damage in Systemic Lupus Erythematosus

OBJECTIVE

To estimate the effect of current poverty, number of years in poverty, and exiting poverty on disease damage accumulation in systemic lupus erythematosus (SLE).

METHODS

For this study, 783 patients with SLE were followed up from 2003 to 2015 through annual structured interviews. Respondents were categorized in each year by whether they had a household income of ≤125% of the US federal poverty level. Linear and logistic regression analyses were used to assess the impact of poverty in 2009, number of years in poverty between 2003 and 2009, and permanent exits from poverty as of 2009 on the extent of disease damage (according to the Brief Index of Lupus Damage [BILD] score) or accumulation of a clinically meaningful increase in disease damage (defined as a minimum 2-point increase in the BILD damage score) by 2015.

RESULTS

After adjustment for sociodemographic features, health care characteristics, and health behaviors, poverty in 2009 was associated with an increased level of accumulated disease damage in 2015 (mean difference in BILD damage score between poor and non-poor 0.62 points, 95% confidence interval [95% CI] 0.25-0.98) and increased odds of a clinically important increase in damage (odds ratio [OR] 1.67, 95% CI 0.98-2.85). Being poor in every year between 2003 and 2009 was associated with greater damage (mean change in BILD score 2.45, 95% CI 1.88-3.01) than being poor for one-half or more of those years (mean change in BILD score 1.45, 95% CI 0.97-1.93), for fewer than one-half of those years (mean change in BILD score 1.49, 95% CI 1.10-1.88), or for none of those years (mean change in BILD score 1.34, 95% CI 1.20-1.49). Those exiting poverty permanently had similar increases in disease damage (mean change in BILD score 1.30, 95% CI 0.90-1.69) as those who were never in poverty (mean change in BILD score 1.36, 95% CI 1.23-1.50) but much less damage than those who remained in poverty (mean change in BILD score 1.98, 95% CI 1.59-2.38).

CONCLUSION

The effects of current poverty, "dose" of poverty, and exiting poverty suggest that poverty plays a critical role in the accumulation of damage in patients with SLE.

Quality Health Care for Homeless Children: Achieving the AAP Recommendations for Care of Homeless Children and Youth

BACKGROUND

We assessed whether and how health care organizations serving homeless pediatric patients meet recommendations issued by the American Academy of Pediatrics (AAP).

METHODS

We conducted a web-based survey of Health Care for the Homeless (HCH) Program grantees serving children.

RESULTS

Of 169 grantees, 77 (46%) responded. All organizations reported connecting patients to specialty services. Nearly all reported screening for homelessness (90%), facilitating Medicaid enrollment (90%), connecting patients to benefits (94%), addressing underlying causes of homelessness (83%), assisting with transportation (83%), and knowing about the causes of homelessness (76%). Fewer reported integrating comprehensive care into acute visits (61%) or having medical-legal partnerships (57%). Federally qualified health center status was associated with meeting more recommendations. We described barriers and facilitators to meeting recommendations.

DISCUSSION

Health care organizations serving homeless children largely meet AAP recommendations, but integrating comprehensive care into acute visits remains an area for improvement. Disseminating best practices may support guideline adherence.