Neighborhoods matter. A systematic review of neighborhood characteristics and adolescent reproductive health outcomes

Using systems thinking to leverage adolescent sexual and reproductive health in rural Latino communities

Disparities in adolescent sexual and reproductive health (SRH) outcomes in rural areas of the USA persist as a concern in achieving health equity for youth. A growing body of literature recognises that improving adolescents' health necessitates systems thinking to address the culture and environment in which adolescents live. This paper uses systems thinking to identify leverage points to improve adolescent SRH in rural Latino communities in California. We conducted focus group discussions with 22 young people and interviewed 10 adult stakeholders to centre the perspectives of youth and youth-serving professionals. Transcripts were coded and analysed using systems thinking. Five themes were developed: (1) community and cultural norms can be a source of both support and stigma for youth; (2) families are key to supporting health education and services; (3) rural schools provide a central hub for programme delivery; (4) community-based organisations can work to serve rural youth, but limited resources and transport are challenges; and (5) youth face considerable barriers accessing SRH services in their communities. Using systems thinking to identify leverage points and gaps in interactions between system components influencing youth can aid in the development of more holistic and culturally responsive approaches for rural youth SRH.

Indirect Effects of Neighbourhood Socioeconomic Status on Preterm Birth Risk in an Argentine Population

BACKGROUND

Preterm birth (PTB) is the main condition related to perinatal morbimortality worldwide. The aim of this study was to determine the indirect effects of neighbourhood socioeconomic status (NSES) on the risk of spontaneous PTB.

METHODS

We carried out a retrospective case-control study including sociodemographic and obstetric data of multigravid women who gave birth at a maternity hospital in Tucumán, Argentina, between 2005 and 2010: 949 women without previous PTB nor pregnancy loss who delivered at term and 552 who had spontaneous PTB. NSES was estimated from the Unsatisfied Basic Needs index of census data. Variables selected through penalised regressions were used to create a data-driven Bayesian network; then, pathways were identified and mediation analyses performed.

RESULTS

Maternal age less than 20 years mediated part of the protective effect of high NSES on spontaneous PTB [natural indirect effect (NIE) -0.0125, 95% confidence interval (CI) (-0.0208, -0.0041)] and on few prenatal visits (< 5) [NIE - 0.0095, 95% CI (-0.0166, -0.0025)]. These pathways showed greater sensitivity to unobserved confounders that affect the variables mediator-outcome in the same direction, and exposure-mediator in the opposite direction. They did not show sensitivity to observed potential confounders, nor to the parameterization used to define NSES. Meanwhile, urinary tract infections showed a trend in mediating the effect of low NSES on spontaneous PTB [NIE 0.0044, 95% CI (-0.0006, 0.0093), P 0.0834].

CONCLUSIONS

High NSES has protective indirect effects on spontaneous PTB risk, mainly associated with a lower frequency of teenage pregnancy.

Effect of multi-level social risk factors on developmental trajectories of sexual risk behaviors among Bahamian middle-to-late adolescents

Background

Few studies have examined how multi-level social factors interact and affect developmental patterns of sexual risk among middle-to-late adolescents who are at risk of experiencing sexual risk behaviors. We examined developmental trajectories of sexual risk behaviors of boys and girls in middle-to-late adolescence and the effects of exposure to three social risk factors (poor parental monitoring, peer risk, and neighborhood risk).

Methods

We followed 2,332 Bahamian adolescents every six months from Grades 10-12. We used group-based trajectory modeling to identify distinct trajectories of sexual risk behaviors for boys and girls.

Results

We identified three trajectories each for boys and girls. Peer risk and neighborhood risk predicted a high sexual-risk trajectory for boys, and peer risk (alone or combined with other risk factors) had the greatest impact on the membership of moderate-to-high-risk trajectory for girls. Parental monitoring had a relatively small effect on adolescents' sexual risk behavior.

Conclusion

Our results underscore the importance of early identification of adolescents with sexual risk behavior and development of targeted prevention interventions to improve adolescent health outcomes.

The combined effects of adverse childhood experiences and neighborhood quality on child health and well-being

BACKGROUND

Many studies have investigated the effects of adverse childhood experiences (ACEs) on the health, development, and well-being of children and adolescents. However, most studies have failed to examine whether childhood adversity and ecological factors interact to influence relevant health outcomes.

OBJECTIVE

We used pooled data from the 2018-19 National Survey of Children's Health (n = 24,817) to assess the relationship between ACEs, neighborhood quality, and three domains of adolescent health and well-being: mental health (i.e., symptoms of anxiety problems and depression), neurodevelopmental health, and behavioral problems.

METHODS

Nine types of ACEs were captured in the NSCH data. Logistic regression models were employed to explore the relationship between ACEs, neighborhood quality, and adolescent health and well-being.

RESULTS

Our results indicate that ACEs are associated with each of these domains, with higher ACE scores associated with a higher risk of detrimental outcomes. Neighborhood disorder is also associated with several outcomes. Consistent with our expectations, in the presence of neighborhood disorder the association between higher ACEs exposure and behavior/conduct problems or neurodevelopmental disorders is larger.

CONCLUSIONS

Our results have important implications for understanding how individual and contextual factors may combine to influence child health and behaviors, as well as offering policy recommendations that might help children who experience traumatic events.

Development and validation of a community risk score for sexual and reproductive health in the United States

Equitable access to sexual and reproductive health (SRH) care is key to reducing inequities in SRH outcomes. Publicly funded family-planning services are an important source of SRH care for people with social risk factors that impede their access. This study aimed to create a new index (Local Social Inequity in SRH [LSI-SRH]) to measure community-level risk of adverse SRH outcomes based on social determinants of health (SDoH). We evaluated the validity of the LSI-SRH scores in predicting adverse SRH outcomes and the need for publicly funded services. The data were drawn from more than 200 publicly available SDoH and SRH measures, including availability and potential need for publicly supported family planning from the Guttmacher Institute. The sample included 72 999 Census tracts (99.9%) in the 50 states and the District of Columbia. We used random forest regression to predict the LSI-SRH scores; 42 indicators were retained in the final model. The LSI-SRH model explained 81% of variance in the composite SRH outcome, outperforming 3 general SDoH indices. LSI-SRH scores could be a useful for measuring community-level SRH risk and guiding site placement and resource allocation.

When everyone's doing it: The relative effects of geographical context and social determinants of health on teen birth rates

Geographic disparities in teen birth rates in the U.S. persist, despite overall reductions over the last two decades. Research suggests these disparities might be driven by spatial variations in social determinants of health (SDOH). An alternative view is that "place" or "geographical context" affects teen birth rates so that they would remain uneven across the U.S. even if all SDOH were constant. We use multiscale geographically weighted regression (MGWR) to quantify the relative effects of geographical context, independent of SDOH, on county-level teen birth rates across the U.S. Findings indicate that even if all counties had identical compositions with respect to SDOH, strong geographic disparities in teen birth rates would still persist. Additionally, local parameter estimates show the relationships between several components of SDOH and teen birth rates vary over space in both direction and magnitude, confirming that global regression techniques commonly employed to examine these relationships likely obscure meaningful contextual differences in these relationships. Findings from this analysis suggest that reducing geographic disparities in teen birth rates will require not only ameliorating differences in SDOH across counties but also combating community norms that contribute to high rates of teen birth, particularly in the southern U.S. Further, the results suggest that if geographical context is not incorporated into models of SDOH, the effects of such determinants may be interpreted incorrectly.

Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study

Introduction

Research suggests neighbourhood socioeconomic vulnerability is negatively associated with women's likelihood of receiving adequate prenatal care and achieving desired postpartum permanent contraception. Receiving adequate prenatal care is linked to a greater likelihood of achieving desired permanent contraception, and access to such care may be critical for women with Medicaid insurance given that the federally mandated Medicaid sterilization consent form must be signed at least 30 days before the procedure. We examined whether adequacy of prenatal care mediates the relationship between neighbourhood socioeconomic position and postpartum permanent contraception fulfilment, and examined moderation of relationships by insurance type.

Methods

This secondary analysis of a retrospective cohort study examined 3012 Medicaid or privately insured individuals whose contraceptive plan at postpartum discharge was permanent contraception. Path analysis estimated relationships between neighbourhood socioeconomic position (economic hardship and inequality, financial strength and educational attainment) and permanent contraception fulfilment by hospital discharge, directly and indirectly through adequacy of prenatal care. Multigroup testing examined moderation by insurance type.

Results

After adjusting for age, parity, weeks of gestation at delivery, mode of delivery, race, ethnicity, marital status and body mass index, having adequate prenatal care predicted achieving desired sterilization at discharge (β = 0.065, 95% confidence interval [CI]: 0.011, 0.117). Living in neighbourhoods with less economic hardship (indirect effect -0.007, 95% CI: -0.015, -0.001), less financial strength (indirect effect -0.016, 95% CI: -0.030, -0.002) and greater educational attainment (indirect effect 0.012, 95% CI: 0.002, 0.023) predicted adequate prenatal care, in turn predicting achievement of permanent contraception by discharge. Insurance status conditioned some of these relationships.

Conclusion

Contact with the healthcare system via prenatal care may be a mechanism by which neighbourhood socioeconomic disadvantage affects permanent contraception fulfilment, particularly for patients with Medicaid. To promote reproductive autonomy and healthcare equity, future inquiry and policy might closely examine how neighbourhood social and economic characteristics interact with Medicaid mandates.

Female adolescent sexual reproductive health service utilization concerns: A qualitative enquiry in the Tema metropolis of Ghana

BACKGROUND

Evidence globally indicates that female adolescents face numerous sexual and reproductive health (SRH) risks. Utilization of sexual reproductive health services among adolescents is of global health importance and plays a crucial role in adolescent sexual reproductive health outcomes and their quality of life.

AIM

The current study explored sexual reproductive health service utilization concerns among female adolescents in the Tema Metropolis in Southern Ghana using the Anderson and Newman Behavioural model of Health Service Utilization as a guiding framework.

METHODS

The study utilized a qualitative exploratory descriptive design. Purposive sampling was used to recruit female adolescents. In-depth face-to-face interviews were conducted using a semi-structured interview guide. In all, 12 interviews were conducted. Each interview lasted between 45 and 60 minutes. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic content analysis. Thematic analysis was guided by the constructs of the Anderson and Newman Behavioural model of health service utilization.

RESULTS

Utilization of sexual reproductive health services among female adolescents is low in the Tema metropolis. Factors such as unprotected non-consensual sexual activity or an unwanted pregnancy sometimes triggered the use of these services. Barriers to utilization identified include lack of awareness on sexual reproductive health services, unreliable sources of SRH information, underestimation of the severity of sexual reproductive health problems faced, unmet expectations and poor experiences with service providers.

CONCLUSION

The current study identified poor utilization of sexual reproductive health services among female adolescents within the Tema metropolis of Ghana. There is the need to increase the number of adolescent health corners, increase awareness about SRH services among adolescents, improve parent-child SRH communication and provide adequate training for healthcare providers to improve provider attitude towards adolescent SRH service delivery in order to increase utilization of sexual reproductive health services among female adolescents in the Metropolis.

Neighborhood characteristics and HIV treatment outcomes: A scoping review

Recognizing challenges faced by people living with HIV is vital for improving their HIV treatment outcomes. While individual-level interventions play a crucial role, community factors can shape the impact of individual interventions on treatment outcomes. Understanding neighborhood characteristics' association with HIV treatment outcomes is crucial for optimizing effectiveness. This review aims to summarize the research scope on the association between neighborhood characteristics and HIV treatment outcomes. The databases PubMed, CINAHL (EBSCOhost), Embase (Elsevier), and PsychINFO (EBSCOhost) were searched from the start of each database to Nov 21, 2022. Screening was performed by three independent reviewers. Full-text publications of all study design meeting inclusion criteria were included in the review. There were no language or geographical limitations. Conference proceedings, abstract only, and opinion reports were excluded from the review. The search yielded 7,822 publications, 35 of which met the criteria for inclusion in the review. Studies assessed the relationship between neighborhood-level disadvantage (n = 24), composition and interaction (n = 17), social-economic status (n = 18), deprivation (n = 16), disorder (n = 8), and rural-urban status (n = 7) and HIV treatment outcomes. The relationship between all neighborhood characteristics and HIV treatment outcomes was not consistent across studies. Only 7 studies found deprivation had a negative association with HIV treatment outcomes; 6 found that areas with specific racial/ethnic densities were associated with poor HIV treatment outcomes, and 5 showed that disorder was associated with poor HIV treatment outcomes. Three studies showed that rural residence was associated with improved HIV treatment outcomes. There were inconsistent findings regarding the association between neighborhood characteristics and HIV treatment outcomes. While the impact of neighborhood characteristics on disease outcomes is highly recognized, there is a paucity of standardized definitions and metrics for community characteristics to support a robust assessment of this hypothesis. Comparative studies that define and assess how specific neighborhood indicators independently or jointly affect HIV treatment outcomes are highly needed.

Effect of a Randomized Controlled Trial of Housing Vouchers on Adolescent Risky Sexual Behavior Over a 15-Year Period

We examined whether a housing voucher intervention influenced adolescent risky sexual behavior (RSB) across 15 years in the Moving to Opportunity Study. Low-income families in public housing that resided in 5 cities were randomized to one of three treatment groups: a housing voucher to move to low-poverty neighborhoods (i.e., < 10% poverty rate), a Sect. 8 voucher but no housing relocation counseling, or a control group that could remain in public housing. Youth and their caregivers completed baseline surveys, as well as two uniform follow-ups: interim (2001-2002; 4-7 years after baseline) and final (2008-2010; 10-15 years after baseline). Approximately 4,600 adolescents (50.5% female) aged 13-20 years participated at the final timepoint. Adolescents reported on their RSB, including condom use, other contraceptive use, early sexual initiation (< 15 years old), and 2+ sexual partners in the past year. We modeled each indicator separately and as part of a composite index. We tested baseline health vulnerabilities as potential effect modifiers. The low-poverty voucher group and the Sect. 8 voucher group were combined due to homogeneity of their effects. Applying intent-to-treat (ITT) regression analyses, we found no significant main effects of voucher receipt (vs. control) on any RSB. However, we found protective effects of voucher receipt on RSB among youth with health problems that limited activity, and youth < 7 at baseline but adverse effects among females, youth > 7 at baseline, and youth who were suspended/expelled from school. Results highlight the importance of understanding how housing interventions differentially influence adolescent health and behaviors.

A systematic review of social processes and mechanisms in the community that influence risky sexual behaviour among adolescents and young adults

AIMS

To examine the associations between social processes and mechanisms within the community and risky sexual behaviour (RSB) among adolescents and young adults.

DESIGN

Systematic review.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and conducted a literature search in August 2020. From 11,216 identified articles, 605 were for full-text screen. We used 24 articles, 22 after applying inclusion criteria and 2 manually searched relevant articles.

RESULTS

Social processes and mechanisms within the community included collective efficiency and social support, community safety and community norm. Collective efficacy and social support and community safety were examined using 10 and 16 studies, respectively. We found that collective efficiency and social support, and community norms partially supported the occurrences of RSB among adolescents and young adults. Community safety displayed inconclusive relationships with RSB.

CONCLUSIONS

The findings highlight the importance of social processes and mechanisms within the community in preventing RSB among adolescents and young adults. Community-based programs to improve community efficacy and social support would be effective strategies to reduce such RSB and to promote better reproductive health among adolescents and young adults.

Examining the effects of cumulative environmental stressors on Gulf Coast child and adolescent health

This study examines how community-level cumulative environmental stress affects child and adolescent emotional distress and chronic health conditions both directly and indirectly through stressors at the household, family, and individual levels. Data comes from the Women and their Children's Health (WaTCH) Study, which sought to understand the health implications of exposure to the 2010 Deepwater Horizon oil spill (DHOS) among a cohort of 596 mothers with children ages 10 to 17 in southeastern Louisiana. Community-level environmental stress was measured using a newly developed geospatial index. Household-level stressors included previous hurricane impacts, impacts of DHOS, degree of financial difficulty, and degree of housing physical decay. Family stressors included maternal depression, self-rated physical health, and degree of parenting stress. Child stress was based on perceived stress; child mental health was based on serious emotional disturbance; and child physical health was based on diagnosis of chronic illness. Structural equation modeling used weighted least squares means and variance and theta parameterization. Results showed a significant negative direct path between community-level cumulative environmental stress and child/adolescent serious emotional disturbance and chronic illness. However, the indirect relationship through household, family, and individual-level stressors was significant and positive for both child/adolescent serious emotional disturbance and chronic illness. These findings point to the centrality of the household and family in determining child and adolescent physical and mental health outcomes in communities exposed to frequent disasters and ongoing environmental stressors.

Association of service facilities and amenities with adolescent birth rates in Mexican cities

BACKGROUND

The association of the built environment and the structural availability of services/amenities with adolescent birth rates (ABR) has been overlooked in Latin America. We investigated the association of the availability, and changes in the availability, of services/amenities with ABR in 92 Mexican cities.

METHODS

We estimated ABR using data on live birth registration linked to municipality of residence at the time of birth from 2008-2017. The number of services/amenities were obtained from the National Statistical Directory of Economic Units in 2010, 2015, and 2020 and grouped as follows: education, health care, pharmacies, recreation, and on- and off-premises alcohol outlets. Data were linearly interpolated to obtain yearly estimates. We estimated densities per square km by municipality. We fitted negative binomial hybrid models, including a random intercept for municipality and city, and adjusted for other social environment variables.

RESULTS

After adjustment a 1-unit increase in the density of recreation facilities, pharmacies, and off-premises alcohol outlets within municipalities was associated with a 5%, 4% and 12% decrease in ABR, respectively. Municipalities with higher density of education, recreational and health care facilities had a lower ABR; in contrast, municipalities with a higher density of on-premises alcohol experienced a higher ABR.

CONCLUSION

Our findings highlight the importance of economic drivers and the need to invest in infrastructure, such as pharmacies, medical facilities, schools, and recreation areas and limit the availability of alcohol outlets to increase the impact of current adolescent pregnancy prevention programs.

The intersection of neighborhood and race in urban adolescent health risk behaviors

AIMS

Racial variability in associations of neighborhood socioeconomic disadvantage and neighborhood disorder with adolescent health risk behaviors remains under-researched, which this study examined over 1 year among racially diverse adolescents.

METHODS

High school students (N = 345; 18% Asian, 44% Black, 16% Multiracial, 22% White) completed surveys assessing neighborhood socioeconomic disadvantage and neighborhood disorder, and health risk behaviors (lifetime alcohol, cannabis, and cigarette use, number of sexual partners) at baseline (Year 1) and 1-year follow-up (Year 2).

RESULTS

Asian, Black, and Multiracial adolescents were more likely to endorse health risk behaviors in Year 2 compared to White adolescents living in similarly disadvantaged neighborhoods at Year 1. Associations of neighborhood disorder with health risk behavior did not differ by race.

CONCLUSION

Neighborhood socioeconomic disadvantage (but not neighborhood disorder) may predispose Asian, Black, and Multiracial adolescents to health risk behaviors. Findings may inform interventions to address racial disparities in adolescent health risk behaviors.

Community characteristics and the risk of non-communicable diseases in Ghana

Non-communicable Diseases (NCDs) are rising quickly in low- and middle- income countries. In Ghana, chronic diseases are major causes of morbidity and mortality, yet data and the evidence- base for awareness, detection, and management of NCDs are lacking. Using data from the 2014 Ghana Demographic and Health Survey (GDHS), the first national study with information on hypertension and other risk factors, we examine the correlates and community characteristics associated with the risk of hypertension, obesity, and anemia among women. We find that hypertension prevalence in Ghana was 16 percent and 17 percent were overweight/obese, while 41 percent had anemia of any form. On community characteristics, the level of poverty in a community was significantly associated with lower risks of all three NCDs, while the aggregate level of employment had higher risks. On individual characteristics, the wealth of a household, women's educational level and urban residence were significant predictors of NCDs. We interpret the findings within the literature on neighborhood characteristics, the social gradient of health and in the context of speeding up the attainment of the Sustainable Development Goals (SGDS) to reduce premature deaths by one-third by 2030.

Accessibility of HIV Services in Philadelphia: Location-Allocation Analysis

INTRODUCTION

As the first step in the HIV care continuum, timely diagnosis is central to reducing transmission of the virus and ending the HIV epidemic. Studies have shown that distance from a testing site is essential for ease of access to services and educational material. This study shows how location-allocation analysis can be used to improve allocation of HIV testing services utilizing existing publicly available data from 2015 to 2019 on HIV prevalence, testing site location, and factors related to HIV in Philadelphia, Pennsylvania.

METHODS

The ArcGIS Location-Allocation analytic tool was used to calculate locations for HIV testing sites using a method that minimizes the distance between demand-point locations and service facilities. ZIP code level demand was initially specified on the basis of the percentage of late HIV diagnoses and in a sensitivity analysis on the basis of a composite of multiple factors. Travel time and distance from demand to facilities determined the facility location allocation. This analysis was conducted from 2021 to 2022.

RESULTS

Compared with the 37 facilities located in 20 (43%) Philadelphia ZIP codes, the model proposed reallocating testing facilities to 37 (79%) ZIP codes using percent late diagnoses to define demand. On average, this would reduce distance to the facilities by 65% and travel time to the facilities by 56%. Results using the sensitivity analysis were similar.

CONCLUSIONS

A wider distribution of HIV testing services across the city of Philadelphia may reduce distance and travel time to facilities, improve accessibility of testing, and in turn increase the percentage of people with knowledge of their status.

Care friendliness in adolescent sexual and reproductive health services in Mexico and a characterisation of their clients

BACKGROUND

Sexual and reproductive health (SRH) is a very important issue in public health programs in low -and middle-income countries (LMICs). Health services that meet specific and differentiated needs of adolescents are increasingly relevant in LMICs. To provide quality services, it is necessary to know the profile of its users and the perspective that adolescents have about SRH services aimed at them.

METHODS

We conducted a cross-sectional analysis of primary data from a survey of 489 adolescents recruited in 11 primary-care facilities in the state of Morelos, Mexico. We followed the guidelines outlined in the World Health Organization Quality Assessment Guidebook: A guide to assessing health services for adolescent clients. Data on friendliness of services were obtained through 70 questions divided into 18 characteristics which, in turn, were grouped into five domains: equity, accessibility, acceptability, appropriateness, and effectiveness. The "friendliness" (a proxy for quality of care) of services was measured according to an additive index of friendliness (FI) ranging from 0 (no friendliness) to 1 (maximum friendliness). We also described the socio-demographic, SRH, and service utilization profiles of clients.

RESULTS

The health services analysed were characterised as having low levels of accessibility (FI = 0.62) and effectiveness (FI = 0.77), moderate acceptability (FI = 0.84), and high levels of appropriateness (FI = 0.93) and equity (FI = 0.92). Of the total number of adolescents surveyed, 51% stated that they had initiated a sexual life, 37% did not use any method of protection during their first sexual intercourse and 64% of the adolescents had already experienced a pregnancy.

CONCLUSIONS

It is essential to improve the accessibility and effectiveness dimensions of adolescent-friendly services in Mexico. This requires the implementation of strategies specifically designed to promote well-informed, planned and healthy sexual behaviours that avert risk and vulnerability. Strategies need to consider the profile of the adolescent client population.

Socially Disadvantaged Community Structures and Conditions Negatively Influence Risky Sexual Behavior in Adolescents and Young Adults: A Systematic Review

Objectives: This review aims to examine the association between community-level factors, namely, community structure and condition, and risky sexual behavior (RSB) including early sexual debut, having multiple sex partners, and unprotected sex, in adolescents and young adults.

Methods: In total, 17 observational studies were identified for review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Among the 11,216 identified articles, excluded articles comprised 8,361 duplicates, 2,855 articles by title screening, 893 by abstract screening, and 667 by full-text screening. Finally, eight additional articles were added by manual search.

Results: The community structural factors included social disadvantage, economic, employment, education status, racial or ethnic composition, residential stability, and physical environment. The current review found that social disadvantage (six studies) and economic status (10 studies) were most frequently examined. Particularly, higher levels of social disadvantage were associated with higher rates of early sexual initiation, inconsistent condom use, and multiple sexual partners.

Conclusion: This study highlights that community structure and conditions in terms of social disadvantages should be addressed to prevent RSB in the young population.

Adolescent birth rates and the urban social environment in 363 Latin American cities

Introduction

Latin America has the second-highest adolescent birth rate (ABR) worldwide. Variation between urban and rural areas and evidence linking country development to ABR points towards upstream factors in the causal pathway. We investigated variation in ABR within and between cities, and whether different features of urban social environments are associated with ABR.

Methods

We included 363 cities in 9 Latin American countries. We collected data on social environment at country, city and subcity levels and birth rates among adolescents (ages 15–19). We investigated variation in ABR within and between countries and cities along with associations between social environment and ABR by fitting three-level negative binomial models (subcities nested within cities nested within countries).

Results

The median subcity ABR was 58.5 per 1000 women 15–19 (IQR 43.0–75.3). We found significant variability in subcity ABR between countries and cities (37% of variance between countries and 47% between cities within countries). Higher homicide rates and greater population growth in cities were associated with higher ABR (rate ratio (RR) 1.09; 95% CI 1.06 to 1.12 and RR 1.02; 95% CI 1.00 to 1.04, per SD, respectively), while better living conditions and educational attainment in subcities were associated with lower ABR after accounting for other social environment characteristics (RR 0.95; 95% CI 0.92 to 0.98 and 0.78; 95% CI 0.76 to 0.79, per SD, respectively).

Conclusions

The large heterogeneity of ABR found within countries and cities highlights the key role urban areas have in developing local policies. Holistic interventions targeting education inequalities and living conditions are likely important to reducing ABR in cities.

Sexual and Reproductive Health Protective Factors among Adolescents with Child Welfare Involvement

Youth with child welfare involvement experience disproportionate rates of sexual and reproductive health (SRH) risks and adverse outcomes. However, little is known about SRH protective factors among youth with child welfare involvement. This study examined whether birth control knowledge or SRH agency, norms, and expectancies differed by gender, age, race/ethnicity, or out-of-home care status among 245 youth, ages 12-15, with open child welfare cases due to maltreatment. Less than half of participants had received information on birth control or knew how to access birth control services; however, the majority reported high confidence in avoiding sex when not desired, strong peer norms for condoms, and few perceived benefits to unprotected sex. Males and younger adolescents had fewer protective attitudes and birth control knowledge, while Latinas had more protective attitudes. This study highlights the protective SRH attitudes already held by youth (ages 12-15) with child welfare involvement, as well as the need for early and gender-inclusive SRH education.

Early Sexual Debut and Neighborhood Social Environment in Latinx Youth

OBJECTIVES

To examine whether social aspects of the neighborhood environment are associated with early sexual initiation in a California agricultural community of predominantly Latinx adolescents.

METHODS

In a prospective cohort study of 599 eighth graders recruited from middle schools in Salinas, California (2015-2019), participants completed five interviews over 2 years. Social environment measures included neighborhood social dynamics (neighborhood disorder, social cohesion, and social network gang exposure); experiences of discrimination; and school connectedness. We estimated associations between baseline social environment and early sexual initiation (<15 years) using Poisson regression with robust standard errors. We compared contraceptive self-efficacy and attitudes by sexual initiation status using ANOVA.

RESULTS

Most youth were Latinx (94%) and age 13 (70%) at enrollment; 53% were female and 49% had a parent employed in agriculture. Additionally, 14% reported first vaginal sex before age 15. Neighborhood disorder (relative risk [RR], 1.13; 95% confidence interval [CI], 1.05-1.21), social network gang exposure (RR, 2.23; 95% CI, 1.49-3.33), and experiences of discrimination (RR, 1.67 [1-2 events versus none], 95% CI, 1.09-2.55; RR, 2.33 [3+ events versus none], 95% CI, 1.07-4.64) were associated with early sexual initiation. School connectedness was protective (RR, 0.44, 95% CI, 0.29-0.69). Youth who initiated sex before age 15 had more negative birth control attitudes and expressed lower motivation to use contraceptives.

CONCLUSIONS

Findings underscore opportunities to promote early adolescent sexual health through strengthening supportive and safe neighborhood environments with the promise of addressing disparities in unintended pregnancy and sexually transmitted infection rates in later adolescence.

Understanding the Psychological Impacts of Teenage Pregnancy through a Socio-ecological Framework and Life Course Approach

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

Individual- and neighborhood-level socioeconomic status and risk of aggressive breast cancer subtypes in a pooled cohort of women from Kaiser Permanente Northern California

BACKGROUND

Low socioeconomic status (SES) has been associated with a higher risk of aggressive breast cancer (BC) subtypes, but few studies have examined the independent effects of both neighborhood-level socioeconomic status (nSES) and individual-level SES measures.

METHODS

This study included 5547 women from the Pathways and Life After Cancer Epidemiology cohorts who were diagnosed with invasive BC. Generalized estimating equation models were used to examine associations of nSES (a composite score based on income, poverty, education, occupation, employment, rent, and house value) and individual-level SES (income and education) with BC subtypes: luminal B (LumB), Her2-enriched (Her2-e), and triple-negative breast cancer (TNBC) relative to luminal A (LumA). Models controlled for age, race, nativity, stage, days from diagnosis to survey, and study cohort and simultaneously for nSES and individual-level SES.

RESULTS

In fully adjusted models, low nSES was significantly associated with the LumB (odds ratio for quartile 1 vs quartile 4 [ORQ1vQ4 ], 1.31; 95% confidence interval [CI], 1.11-1.54; P for trend = .005) and TNBC subtypes (ORQ1vQ4 , 1.32; 95% CI, 1.02-1.71; P for trend = .037) relative to LumA. Conversely, individual education was significantly associated with only the Her2-e subtype (odds ratio for high school degree or less vs postgraduate, 1.68; 95% CI, 1.03-2.75; P for trend = .030) relative to LumA. Individual income was not significantly associated with any BC subtype.

CONCLUSIONS

nSES and individual-level SES are independently associated with different BC subtypes; specifically, low nSES and individual-level education are independent predictors of more aggressive BC subtypes relative to LumA.

Neighborhood structural characteristics, perceived neighborhood environment, and problem behaviors among at-risk adolescents

Neighborhood environment has been linked to behavioral outcomes in adolescence. The current study examined two potential mediators (i.e., perceived social capital, perceived neighborhood disorder) in the association between neighborhood structural characteristics (i.e., neighborhood disorganization) and problem behaviors (i.e., externalizing behavior, substance use) among at-risk adolescents with prenatal substance exposure. The study sample included 350 15-year-old adolescents recruited at birth. Adolescents' addresses were linked to census tract data. Neighborhood structural characteristics were not directly associated with adolescent problem behaviors in the presence of perceived social capital and neighborhood disorder. Greater neighborhood disorganization was associated with lower levels of perceived social capital, which was related to greater perceived neighborhood disorder, and then problem behaviors. The findings suggest that community practice needs to focus on subjective perceptions of neighborhoods when developing intervention programs on problem behaviors among at-risk adolescents.

A multi-scalar perspective on health and urban housing: an umbrella review

With more than half the world's population living in cities, understanding how the built environment impacts human health at different urban scales is crucial. To be able to shape cities for health, an understanding is needed of planetary health impacts, which encompass the human health impacts of human-caused disruptions on the Earth's natural ecosystems. This umbrella review maps health evidence across the spatial scales of the built environment (building; neighbourhood; and wider system, including city, regional and planetary levels), with a specific focus on urban housing. Systematic reviews published in English between January 2011 and December 2020 were searched across 20 databases, with 1176 articles identified and 124 articles screened for inclusion. Findings suggests that most evidence reports on health determinants at the neighbourhood level, such as greenspace, physical and socio-economic conditions, transport infrastructure and access to local services. Physical health outcomes are also primarily reported, with an emerging interest in mental health outcomes. There is little evidence on planetary health outcomes and significant gaps in the research literature are identified. Based on these findings, three potential directions are identified for future research.

Childhood residential mobility and health outcomes: A meta-analysis

This study assesses the association between childhood residential mobility and health-related outcomes by way of a meta-analysis of studies published between 1989 and 2020. The sample includes 844 effect sizes from 64 unique studies. The results point to a negative association (small to medium) between childhood mobility and health. This association is contingent upon the type of health outcome studied, age at outcome assessment, age at moving, and frequency of moves. The major confounders of this association are parental SES, parental marital status, ethnicity, and co-occurring childhood adversities. The implications for future research are discussed.

Adolescent Birth Rates and Rural-Urban Differences by Levels of Deprivation and Health Professional Shortage Areas in the United States, 2017-2018

Objectives. To examine the differences in adolescent birth rates by deprivation and Health Professional Shortage Areas (HPSAs) in rural and urban counties of the United States in 2017 and 2018.Methods. We analyzed available data on birth rates for females aged 15 to 19 years in the United States using the restricted-use natality files from the National Center for Health Statistics, American Community Survey 5-year population estimates, and the Area Health Resources Files.Results. Rural counties had an additional 7.8 births per 1000 females aged 15 to 19 years (b = 7.84; 95% confidence interval [CI] = 7.13, 8.55) compared with urban counties. Counties with the highest deprivation had an additional 23.1 births per 1000 females aged 15 to 19 years (b = 23.12; 95% CI = 22.30, 23.93), compared with less deprived counties. Rural counties with whole shortage designation had an additional 8.3 births per 1000 females aged 15 to 19 years (b = 8.27; 95% CI = 6.86, 9.67) compared with their urban counterparts.Conclusions. Rural communities across deprivation and HPSA categories showed disproportionately high adolescent birth rates. Future research should examine the extent to which contraceptive access differs among deprived and HPSA-designated rural communities and the impact of policies that may create barriers for rural communities.

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward

Attempts to solve the "problem of adolescent pregnancy" have long been a  focus of national, state, and local efforts in the United States. This review article summarizes trends and strategies around adolescent pregnancy prevention, provides lessons learned and best practices, and presents ideas for future directions. Over the past decades, a wide variety of policy and programmatic interventions have been implemented - including educational efforts, clinical health services, and community-wide coalitions - accompanied by a growing consensus regarding viable solutions. While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist. Many adolescents who most need sexual health information and services are underserved by current programs and policies. A growing understanding of the role of social determinants of health, the impacts of structural racism, and the need for equity and inclusion must inform the next set of interventions and societal commitments to not only ameliorate the occurrence of unintended adolescent pregnancy but also foster healthy adolescent development. Recommendations for future efforts include improving the content, quality, and sustainability of education programs; actively engaging youth in the design of policies, programs, and clinical services; using technology thoughtfully to improve health literacy; expanding access to services through telehealth and other delivery options; and designing programs and policies that recognize and address structural racism, health equity, and inclusion.

Neighborhoods and health during the transition to adulthood: A scoping review

Research suggests that neighborhoods play an important role in shaping health outcomes across the life course, but the neighborhood-health link during the transition to adulthood period (18-29 years) is not well studied. A scoping review of 24 studies used thematic analysis to examine the theoretical and methodological approaches of the neighborhood-health literature during this period. Themes illustrate the varied approaches used in this research, including diversity in how neighborhood is defined, theoretical variation regarding the importance of the transition period and the neighborhood-health link, and the importance of gender and race/ethnicity to this area of study. While the literature on this topic is fragmented, with varied definitions and minimal theoretical coherence, all studies found some degree of support for the relationship between neighborhoods and health during the transition to adulthood. Our analysis suggests that future research should focus on developing a theoretical foundation for these relationships in order to clarify key concepts and advance a science to better understand how and why neighborhoods affect health during this period.

Trends in Adolescent Birth Rates in California: Examining the Influence of Community Characteristics Through Geographic and Temporal Analysis

PURPOSE

The aim of the article was to understand community-level factors associated with the decline in the adolescent birth rate (ABR) in California from 2000 to 2014.

METHODS

We consolidated multiple data sources at the level of the Medical Service Study Area (MSSA), a federally recognized subcounty geographic unit (N = 497). We used ordinary least squares regression to examine predictors of change in the ABR at the MSSA level over three periods of notable change in California's ABR: 2000-2002, 2006-2008, and 2012-2014. Variables assessed include geographic density, change in sociodemographic and economic characteristics, and change in the availability of publicly funded sexual health services.

RESULTS

The ABR declined more in urban than rural MSSAs. In the earlier period, growth in the black, Hispanic, and foreign-born populations, unemployment, and receipt of public assistance were associated with smaller declines in the ABR. Growth in the share of married households and high school completion were associated with larger declines in the ABR. In the later period, growth in public assistance receipt was associated with smaller declines in the ABR, whereas growth in high school completion and college attendance were associated with larger declines. Decline in the ABR was steeper in areas that began offering publicly funded long-acting contraception to adolescents. Rural-urban differences were no longer significant after controlling for change in the provision of long-acting contraception.

CONCLUSIONS

Identifying the independent contributions of changes in sociodemographic, economic, and service characteristics to changes in the ABR supports the development of programs and policies that are more responsive to the communities they serve.

A housing mobility program's impacts on teen and young adult parenting

OBJECTIVE

To assess the impact of Moving to Opportunity for Fair Housing Demonstration Program (MTO) implemented in 1994 in five U.S. cities (Baltimore, Boston, Chicago, Los Angeles, and New York City) on teen births.

METHODS

We analyzed baseline and long-term evaluation data for youth (ages 13-20) and young adults (ages 21-30) (N = 7861) who were children or teens at baseline. We used regression analyses to estimate the impact of housing vouchers on having a teen birth.

RESULTS

Overall, MTO had no significant effect on teen births. However, among young adults whose parent had a child before age 20, the proportion with a teen birth themselves was 21% lower among those offered housing vouchers to low-poverty neighborhoods with no restrictions compared to those not offered housing vouchers (p < 0.05).

CONCLUSION

MTO appeared to decrease intergenerational teen births among young adults. Further exploration of housing relocation may help untangle risks and protective factors for reducing intergenerational teen births.

PUBLIC HEALTH IMPLICATIONS

Reducing intergenerational teen births is important, especially among those facing economic, environmental, and health risks. Comprehensive programs addressing multiple social determinants of health are vital to reducing teen births.

Prevalence of Sexual Initiation Before Age 13 Years Among Male Adolescents and Young Adults in the United States

IMPORTANCE

Despite similar sexual activity rates among male and female adolescents, males are more likely to have their first sexual intercourse before age 13 years. The developmental needs and pathways to healthy trajectories for young males remain unknown.

OBJECTIVE

To examine the prevalence of sexual intercourse before age 13 years among male adolescents; the variation by race/ethnicity, location, and maternal educational level; and the wantedness of this first sexual experience.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis was conducted from September 2017 to June 2018, using pooled 2011, 2013, and 2015 data from the school-based Youth Risk Behavior Surveillance System (YRBSS) and the 2006 to 2015 data of males aged 15 to 24 years from the household-based National Survey of Family Growth (NSFG). The percentage of males reporting sexual onset before age 13 years was estimated using survey-weighted logistic regression to test for differences by race/ethnicity within each national survey and within metropolitan areas (for YRBSS, high school and middle school samples). Among NSFG survey respondents, differences in wantedness of first sexual intercourse by age at first sexual intercourse were examined, along with the associations between sexual initiation and socioeconomic covariates.

MAIN OUTCOMES AND MEASURES

Sexual onset before age 13 years.

RESULTS

Data from a total of 19 916 male high school students (from YRBSS) and 7739 males aged 15 to 24 years (from NSFG) were included in the analysis. The sample was largely composed of non-Hispanic white males: 8789 (57.1%) from the YRBSS and 3737 (58.0%) from the NSFG. Sexual onset before age 13 years was reported nationally by 7.6% (95% CI, 6.8%-8.4%) of male high school students and 3.6% (95% CI, 3.0%-4.2%) of males aged 15 to 24 years. The proportion of male students who reported having sexual intercourse before age 13 years varied across metropolitan sites, from 5% (95% CI, 4%-7%) in San Francisco, California, to 25% (95% CI, 23%-28%) in Memphis, Tennessee, with elevated rates among non-Hispanic black and Hispanic males in most metropolitan areas. In the NSFG data set, respondents whose mothers had a college degree or higher educational level were statistically significantly less likely (OR, 0.31; 95% CI, 0.19-0.49) to report having sexual intercourse before age 13 years compared with those whose mothers did not have a college degree. Among males who reported having their first sexual experience before age 13 years, 8.5% (95% CI, 3.8%-17.8%) described their first sexual intercourse as unwanted.

CONCLUSIONS AND RELEVANCE

Rates of sexual onset before age 13 years among young males varied by race/ethnicity, location, and maternal educational level, presenting important implications for the provision of early, inclusive, and comprehensive sex education and sexual and reproductive health care to male children and adolescents.