1
|
Ferreira P, Fraga S, Oliveira A. Association of adverse childhood experiences with dietary patterns of school-age children: evidence from the birth cohort Generation XXI. Am J Clin Nutr 2024; 120:328-335. [PMID: 38857694 DOI: 10.1016/j.ajcnut.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Adverse Childhood Experiences (ACEs) have been associated with health-risk behaviors and several chronic diseases in adulthood. However, the relationship between exposure to ACEs and dietary patterns at school age is unknown. OBJECTIVES To investigate the association between ACEs and dietary patterns of 10-year-olds. METHODS The study included 5034 children from the Generation XXI cohort, recruited in 2005/2006 in Porto, Portugal. ACEs were assessed through a self-administered questionnaire covering the first 10 years (y) of life, quantified and grouped into 5 dimensions: "abuse," "school problems," "death/severe disease," "life changes," and "household dysfunction." Dietary patterns were identified by latent class analysis using data collected with a validated food frequency questionnaire. Five dietary patterns were studied: "low consumption," "energy-dense foods," "snacking," "intermediate consumption," and "healthier" (used as reference). Multinomial regression analyses were conducted, adjusted for the child's sex, household income, family structure, and mother's age [odds ratio (OR) and 99% confidence intervals (CIs)]. RESULTS Most children were exposed to ≥1 ACE (96%), and ∼27% had reported 6 or more ACEs throughout life. Those reporting 4-5 and ≥6 ACEs were more likely to follow the "Energy-dense foods" dietary pattern compared with those with no ACEs (OR: 2.41; 99% CI: 1.00, 5.77 and OR: 2.65; 99% CI: 1.10, 6.39, respectively). Children exposed to "abuse" in the first 10 y showed 28% higher odds of following the "low consumption" dietary pattern when compared to children with no reported ACEs and using the "healthier" dietary pattern as a reference (OR: 1.28; 99% CI: 1.00, 1.63). CONCLUSIONS Exposure to ACEs was associated with less healthy dietary patterns in school-aged children. Results suggest a cumulative effect of the adverse experiences resulting in a dietary pattern higher in energy-dense foods. Children with ACEs reported under the dimension of "abuse" seemed to have reduced food consumption.
Collapse
Affiliation(s)
- Pedro Ferreira
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto (Epidemiology Research Unit, Institute of Public Health, University of Porto), Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Sílvia Fraga
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto (Epidemiology Research Unit, Institute of Public Health, University of Porto), Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Andreia Oliveira
- EPIUnit, Instituto de Saúde Pública, Universidade do Porto (Epidemiology Research Unit, Institute of Public Health, University of Porto), Porto, Portugal; Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal.
| |
Collapse
|
2
|
Cook KM, De Asis-Cruz J, Sitrin C, Barnett SD, Krishnamurthy D, Limperopoulos C. Greater Neighborhood Disadvantage Is Associated with Alterations in Fetal Functional Brain Network Structure. J Pediatr 2024; 274:114201. [PMID: 39032768 DOI: 10.1016/j.jpeds.2024.114201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE To determine the association between neighborhood disadvantage (ND) and functional brain development of in utero fetuses. STUDY DESIGN We conducted an observational study using Social Vulnerability Index (SVI) scores to assess the impact of ND on a prospectively recruited sample of healthy pregnant women from Washington, DC. Using 79 functional magnetic resonance imaging scans from 68 healthy pregnancies at a mean gestational age of 33.12 weeks, we characterized the overall functional brain network structure using a graph metric approach. We used linear mixed effects models to assess the relationship between SVI and gestational age on 5 graph metrics, adjusting for multiple scans. RESULTS Exposure to greater ND was associated with less well integrated functional brain networks, as observed by longer characteristic path lengths and diminished global efficiency (GE), as well as diminished small world propensity (SWP). Across gestational ages, however, the association between SVI and network integration diminished to a negligible relationship in the third trimester. Conversely, SWP was significant across pregnancy, but the relationship changed such that there was a negative association with SWP earlier in the second trimester that inverted around the transition to the third trimester to a positive association. CONCLUSIONS These data directly connect ND and altered functional brain maturation in fetuses. Our results suggest that, even before birth, proximity to environmental stressors in the wider neighborhood environment are associated with altered brain development.
Collapse
Affiliation(s)
- Kevin Michael Cook
- Developing Brain Institute, Children's National Hospital, Washington, DC
| | | | - Chloe Sitrin
- Department of Psychology, College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, MI
| | - Scott D Barnett
- Developing Brain Institute, Children's National Hospital, Washington, DC
| | | | | |
Collapse
|
3
|
Johnson W, Mansukoski L, Galvez-Sobral JA, Furlán L, Bogin B. Inequalities in adiposity trends between 1979 and 1999 in Guatemalan children. Am J Hum Biol 2024; 36:e24031. [PMID: 38148505 DOI: 10.1002/ajhb.24031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/06/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Guatemala suffered from civil war and high levels of inequality and childhood stunting in the second half of the 20th century, but little is known about inequalities in secular trends in adiposity. OBJECTIVES To investigate differences in childhood body mass index (BMI) and skinfold thickness trajectories from 1979 to 1999 between three groups of children: High socioeconomic position (SEP) Ladino, Low SEP Ladino, and Low SEP Indigenous Maya. METHODS The sample comprised 19 346 children aged 7-17 years with 54 638 observations. The outcomes were height, BMI, triceps skinfold thickness (TST), and subscapular skinfold thickness (SST) Z-scores according to the Centers for Disease Control and Prevention (CDC) references. Sex-specific multilevel models were used to estimate and compare mean trajectories from 1979 to 1999 between the three groups. RESULTS Mean Z-scores were always highest for High SEP Ladino children and lowest for Low SEP Maya children. Despite their very short stature, the Low SEP groups had SST trajectories that were above the 50th centile. The BMI trajectories were relatively flat and within one major centile band of the CDC median, with differences between the three groups that were small (0.2-0.3 Z-scores) and did not attenuate over time. Conversely, the TST Z-score trajectories demonstrated larger positive secular trends (e.g., from -1.25 in 1979 to -0.06 in 1999 for Low SEP Maya boys), with differences between the three groups that were large (0.5-1.2 Z-scores) and did attenuate over time (in boys). Secular trends and between-group difference in the SST Z-score trajectories were less pronounced, but again we found stronger evidence in boys that the estimated inequalities attenuated over time. CONCLUSIONS Secular trends and inequalities in skinfolds differ from those for BMI in Guatemalan children. Differences between groups in skinfolds attenuated over time, at least in boys, but whether this is good news is questionable given the very short stature yet relatively large subscapular skinfolds of the Low SEP groups.
Collapse
Affiliation(s)
- William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - J Andres Galvez-Sobral
- Centro de Investigaciones Educativas, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Luis Furlán
- Centro de Estudios en Informática Aplicada, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Barry Bogin
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- UCSD/Salk Center for Academic Research and Training in Anthropogeny (CARTA), USA
| |
Collapse
|
4
|
Carrilero N, García-Altés A. Health inequalities in childhood diseases: temporal trends in the inter-crisis period. Int J Equity Health 2024; 23:76. [PMID: 38632575 PMCID: PMC11025183 DOI: 10.1186/s12939-024-02169-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Since 2008, children in Catalonia (Spain) have suffered a period of great economic deprivation. This situation has generated broad-ranging health inequalities in a variety of diseases. It is not known how these inequalities have changed over time. The aim of the present study is to determine trends in inequalities over this period in ten relevant diseases in children according to sex and age. METHODS A retrospective cross-sectional population-based study of all children under 15 years old resident in Catalonia during the 2014-2021 period (over 1.2 million children/year) and of their diagnoses registered by the Catalan Health System. Health inequalities were estimated by calculating the relative index of inequality and time trends using logistic regression models. Interaction terms were added to test for the effects of sex on time trends. RESULTS Increasing significant temporal trends in inequalities were shown for both sexes in almost all the diseases or adverse events studied (asthma, injuries, poisoning, congenital anomalies, overweight and obesity), in mood disorders in boys, and in adverse birth outcomes in girls. Adjustment and anxiety and mood disorders in girls showed a decreasing temporal trend in inequalities. More than half of the diseases and adverse events studied experienced significant annual increases in inequality. Poisoning stood out with an average annual increase of 8.65% [4.30, 13.00], p ≤ 0.001 in boys and 8.64% [5.76, 11.52], p ≤ 0.001) in girls, followed by obesity with increases of 5.52% [4.15, 6.90], p = < 0.001 in boys and 4.89% [4.26, 5.51], p ≤ 0.001) in girls. CONCLUSIONS Our results suggest that inequalities persist and have increased since 2014. Policy makers should turn their attention to how interventions to reduce Health inequalities are designed, and who benefits from them.
Collapse
Affiliation(s)
- Neus Carrilero
- Agència de Qualitat I Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain.
- Department of Medicine and Life Sciences (MELIS-UPF), Pompeu Fabra University, Barcelona, Spain.
- Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) , Barcelona, Spain.
- Research Group on Primary and Community Care in Barcelona (APICBA), Hospital del Mar Research Institute, Barcelona, Spain.
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Barcelona, Spain.
| | - Anna García-Altés
- Agència de Qualitat I Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Institut d'Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain
| |
Collapse
|
5
|
Reilly S, McKean C. Creating the conditions for robust early language development for all-Part 1: Evidence-informed child language surveillance in the early years. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2023; 58:2222-2241. [PMID: 37432035 DOI: 10.1111/1460-6984.12929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/14/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The emergence of language in the early years is a major developmental accomplishment that underpins learning, enables social interaction and, later, is an indicator of well-being. Learning language is an effortless process for most, but can be challenging for others. There is a need to act early. First, because there are several social, environmental and family factors known to influence how language develops during the critical early years. Second, there is a robust association between a child's socio-economic circumstances and language outcomes. Put simply, children living in less advantaged circumstance have poorer language outcomes, which are apparent very early and persist across the lifespan. Third, children with demonstrated weaknesses in language learning in early childhood have poorer educational, employment, mental health and quality-of-life outcomes across the lifespan. Acting early to counter these impacts is important; however, there are several well-documented challenges in accurately identifying in the early years children who are at later risk of developmental language disorder (DLD) and to deliver prevention and intervention programmes to scale. This is critical because many services do not currently reach those who need them most; as many as 50% of children in need may not be receiving support. AIM To determine whether an improved surveillance system, based on best evidence, could be developed for the early years. METHODS & PROCEDURES We summarised findings from longitudinal, population or community studies that: (1) adopted bioecological models, (2) repeatedly measured language (including the early years) and (3) adopted similar methodologies, to identify factors that influence language outcomes. MAIN CONTRIBUTION The evidence confirmed that language development is not always stable but is characterized by distinct trajectories and each has distinguishing social, environmental features. Children in the change or fluctuating groups tend to live in less advantageous circumstances that may not always support and enable language development. Risk factors tend to cluster and accumulate across the early years and beyond, thereby markedly increasing the likelihood of poorer language outcomes later in life. CONCLUSIONS & IMPLICATIONS In this the first of two papers, designed to be read together, we integrate research on the social determinants of child language and propose they be embedded into surveillance models. This has the potential to reach more children and those living in disadvantaged circumstances. In the accompanying paper we combine this information with evidence-informed early prevention/intervention approaches and propose the design and implementation of an early language public health framework. WHAT THIS PAPER ADDS What is already known on the subject There are several well-documented challenges in accurately identifying in the early years children who are at later risk of DLD and reaching those most in need of language support. What this study adds to existing knowledge A combination of child, family and environmental determinants, collectively and cumulatively, play out over time and dramatically increase the risk of later language problems, in particular those children living in disadvantaged circumstances. We propose an improved surveillance system that incorporates these determinants be developed and that this be part of a whole of system approach to child language in the early years. What are the potential or actual clinical implications of this work? Clinicians intuitively act to prioritize children with multiple features or risks; however, they can only do so for those who present or are identified to be at risk. Given many children with language problems are not being reached by many early language services, it is reasonable to ask if this knowledge can be integrated to improve reach. Or is a different surveillance model required?
Collapse
|
6
|
Zhao M, He X, Li T, Shao H, Huo Q, Li Y. Early-Life Factors and Multimorbidity Risk Later in Older Age: Evidence Based on CHARLS. Gerontology 2023; 69:1347-1357. [PMID: 37725916 DOI: 10.1159/000532060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/17/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION Early-life factors were reported to exert influence on the health condition of individuals in the long-term. However, limited research explored the connection between early-life factors and multimorbidity in later years. METHODS We utilized the data from the China Health and Retirement Longitudinal Study to assess this possible association in the present cross-sectional study. Multimorbidity was determined based on 14 common chronic diseases included in the study. Logistic regression was employed to examine the link between early-life factors and subsequent multimorbidity. RESULTS Out of 7,578 participants who met the inclusion criteria for analysis, 3,765 (49.68%) were females. The mean age was 68.25 ± 6.70 years. Participants who rated their health during childhood as average (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.96) or better [OR 0.72, 95% CI 0.57-0.91] were significantly less likely to experience multimorbidity in older life. By contrast, experiencing violence from two of the family members was significantly associated with future multimorbidity (OR [95% CI], 1.29 [1.04-1.60]). A superior family financial situation was also negatively associated with multimorbidity, with average (OR [95% CI], 0.72 [0.63-0.83]) and better off than average (OR [95% CI], 0.76 [0.62-0.93]). DISCUSSION Individuals with poor health status, inferior family socioeconomic status, or experienced violence from family members in childhood were more likely to suffer from multimorbidity in later life. Enhanced social monitoring of potentially adverse conditions in youngsters and targeted interventions could help mitigate the progression of multimorbidity in later life.
Collapse
Affiliation(s)
- Minjun Zhao
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China,
| | - Xu He
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Tianrong Li
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Heng Shao
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Qian Huo
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Yan Li
- Department of Geriatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| |
Collapse
|
7
|
Baker-Smith CM, Yang W, McDuffie MJ, Nescott EP, Wolf BJ, Wu CH, Zhang Z, Akins RE. Association of Area Deprivation With Primary Hypertension Diagnosis Among Youth Medicaid Recipients in Delaware. JAMA Netw Open 2023; 6:e233012. [PMID: 36920393 PMCID: PMC10018318 DOI: 10.1001/jamanetworkopen.2023.3012] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023] Open
Abstract
Importance The association between degree of neighborhood deprivation and primary hypertension diagnosis in youth remains understudied. Objective To assess the association between neighborhood measures of deprivation and primary hypertension diagnosis in youth. Design, Setting, and Participants This cross-sectional study included 65 452 Delaware Medicaid-insured youths aged 8 to 18 years between January 1, 2014, and December 31, 2019. Residence was geocoded by national area deprivation index (ADI). Exposures Higher area deprivation. Main Outcomes and Measures The main outcome was primary hypertension diagnosis based on International Classification of Diseases, Ninth Revision and Tenth Revision codes. Data were analyzed between September 1, 2021, and December 31, 2022. Results A total of 65 452 youths were included in the analysis, including 64 307 (98.3%) without a hypertension diagnosis (30 491 [47%] female and 33 813 [53%] male; mean [SD] age, 12.5 (3.1) years; 12 500 [19%] Hispanic, 25 473 [40%] non-Hispanic Black, 24 565 [38%] non-Hispanic White, and 1769 [3%] other race or ethnicity; 13 029 [20%] with obesity; and 31 548 [49%] with an ADI ≥50) and 1145 (1.7%) with a diagnosis of primary hypertension (mean [SD] age, 13.3 [2.8] years; 464 [41%] female and 681 [59%] male; 271 [24%] Hispanic, 460 [40%] non-Hispanic Black, 396 [35%] non-Hispanic White, and 18 [2%] of other race or ethnicity; 705 [62%] with obesity; and 614 [54%] with an ADI ≥50). The mean (SD) duration of full Medicaid benefit coverage was 61 (16) months for those with a diagnosis of primary hypertension and 46.0 (24.3) months for those without. By multivariable logistic regression, residence within communities with ADI greater than or equal to 50 was associated with 60% greater odds of a hypertension diagnosis (odds ratio [OR], 1.61; 95% CI 1.04-2.51). Older age (OR per year, 1.16; 95%, CI, 1.14-1.18), an obesity diagnosis (OR, 5.16; 95% CI, 4.54-5.85), and longer duration of full Medicaid benefit coverage (OR, 1.03; 95% CI, 1.03-1.04) were associated with greater odds of primary hypertension diagnosis, whereas female sex was associated with lower odds (OR, 0.68; 95%, 0.61-0.77). Model fit including a Medicaid-by-ADI interaction term was significant for the interaction and revealed slightly greater odds of hypertension diagnosis for youths with ADI less than 50 (OR, 1.03; 95% CI, 1.03-1.04) vs ADI ≥50 (OR, 1.02; 95% CI, 1.02-1.03). Race and ethnicity were not associated with primary hypertension diagnosis. Conclusions and Relevance In this cross-sectional study, higher childhood neighborhood ADI, obesity, age, sex, and duration of Medicaid benefit coverage were associated with a primary hypertension diagnosis in youth. Screening algorithms and national guidelines may consider the importance of ADI when assessing for the presence and prevalence of primary hypertension in youth.
Collapse
Affiliation(s)
- Carissa M. Baker-Smith
- Cardiovascular Research and Innovation Program, Nemours Cardiac Center, Nemours Children’s Health, Wilmington, Delaware
| | - Wei Yang
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mary J. McDuffie
- Center for Community Research and Service, University of Delaware Biden School of Public Policy and Administration, University of Delaware, Newark
| | - Erin P. Nescott
- Center for Community Research and Service, University of Delaware Biden School of Public Policy and Administration, University of Delaware, Newark
| | | | - Cathy H. Wu
- Data Science Institute, University of Delaware, Newark
| | - Zugui Zhang
- Institute for Research in Equity and Community Health, Christiana Care Health Services, Inc, Newark, Delaware
| | - Robert E. Akins
- Center for Pediatric Clinical Research and Development, Nemours Children’s Health, Wilmington, Delaware
| |
Collapse
|
8
|
Qiu C, Feng W, An X, Liu F, Liang F, Tang X, Zhang P, Liang X. The effect of fine particulate matter exposure on allergic rhinitis of adolescents aged 10-13 years: A cross-sectional study from Chongqing, China. Front Public Health 2022; 10:921089. [PMID: 36388289 PMCID: PMC9642846 DOI: 10.3389/fpubh.2022.921089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/26/2022] [Indexed: 01/22/2023] Open
Abstract
Background Allergic rhinitis (AR) has become a tremendous disease burden worldwide. Only a few studies have explored the effects of environmental exposure on the prevalence of AR in children in China. Methods In the present study, we investigated the associations of environmental exposure (including fine particulate matter (PM2.5), air humidity, temperature, and passive smoking) with AR in adolescents aged 10-13 years in Chongqing. Data from 4,146 participants in urban and rural areas between March 2019 and May 2019 were collected. Results The overall prevalence of AR was 17.50% in adolescents. After adjusting for other covariates, AR was positively correlated with the annual mean PM2.5 concentration, monthly mean PM2.5 concentration and air temperature, and negatively related to air humidity. Furthermore, the annual mean PM2.5 was positively associated with the risk of AR after adjusting for air temperature and humidity. Passive smoking (PS) was marginally associated with a high risk of AR. Conclusion High PM2.5 exposure, high air temperature, and low air humidity were associated with a high risk of AR in adolescents. Our findings have potential implications for public health strategies and interventions aimed at reducing the burden of AR in adolescents.
Collapse
Affiliation(s)
- Chunlan Qiu
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Wei Feng
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Xizhou An
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Fangchao Liu
- Department of Epidemiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengchao Liang
- School of Public Health and Emergency Management, Southern University of Science and Technology, Shenzhen, China
| | - Xian Tang
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Ping Zhang
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Xiaohua Liang
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China,*Correspondence: Xiaohua Liang
| |
Collapse
|
9
|
Paciência I, Moreira A, Cavaleiro Rufo J, Santos AC, Barros H, Ribeiro AI. Association between Land Use Mix and Respiratory Symptoms and Asthma in Children from the Generation XXI Birth Cohort. J Urban Health 2022; 99:218-230. [PMID: 35066785 PMCID: PMC9033904 DOI: 10.1007/s11524-021-00604-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
Abstract
Land use mix (LUM) in the neighbourhoods has been associated with healthier lifestyles. However, less is known about the association between LUM and health outcomes, namely during childhood. The objective of this study was to evaluate the association between different LUM indexes for Porto Metropolitan Area and asthma and respiratory symptoms in children. A cross-sectional analysis was performed involving 6260 children enrolled in Generation XXI. Land use around the child's residence was assessed with the Portuguese official map of land cover using a GIS. Generalized linear mixed-effects models were fitted to estimate the association between LUM and respiratory symptoms and asthma at 7 years of age. Adjusted associations were quantified using odds ratio (OR) and 95% confidence interval (95% CI). After adjustment, LUM was associated with a lower odds of wheezing in the last 12 months [OR (95% CI) = 0.37 (0.15; 0.93) using Shannon's Evenness Index within 500 m; and OR = 0.93 (0.89; 0.98) using the number of different land use types within 250 m]. Living in neighbourhoods with high LUM has a protective effect on current wheezing symptoms. Our results highlight the association between LUM and respiratory symptoms among children, suggesting that public health considerations should be incorporated in land use decision-making.
Collapse
Affiliation(s)
- Inês Paciência
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal. .,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal.
| | - André Moreira
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal.,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200- 319, Porto, Portugal.,Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - João Cavaleiro Rufo
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal.,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal
| | - Ana Cristina Santos
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal.,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200- 319, Porto, Portugal
| | - Henrique Barros
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal.,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200- 319, Porto, Portugal
| | - Ana Isabel Ribeiro
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600, Porto, Portugal.,Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas 135, 4050-600, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200- 319, Porto, Portugal
| |
Collapse
|
10
|
M K R K, A S L, A R, S Q, P S. Diagnoses of infectious diseases among Norwegian-born children to immigrant parents - the role of parental socioeconomic position. Scand J Public Health 2022:14034948221082455. [PMID: 35365047 DOI: 10.1177/14034948221082455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Children of immigrants have a higher incidence of infectious disease than native children. Our aim was to assess the role of parental socioeconomic position for diagnoses of infectious disease among children of immigrants. METHODS Data from the Norwegian Patient Registry (on diagnoses from secondary/tertiary care), Medical Birth Registry of Norway, and Statistics Norway were linked by the national personal identification number. Seven diagnostic infection categories were included from 2008 onwards. The study population included children born in Norway aged 0-10 years between 2008 and 2018 (N = 988,647). Hazards of infection diagnoses by parental region of origin (adjusted for sex, birth year, parental education, household income and mother's parity) and by parental education and household income were assessed by Cox regression. RESULTS High parental education was associated with lower hazard of infection diagnoses among children of Norwegian-born parents, but associations were less consistent among children with immigrant parents. Lower household income was related to hazard of most infectious diagnoses among children with both Norwegian-born and immigrant parents. Assessed by region diagnoses of viral and bacterial infections and infections of the musculoskeletal system and soft tissue were not associated with household income. Parental education and household income did not explain differences in hazard of infection diagnoses between children born to immigrant versus Norwegian-born parents. CONCLUSIONS Socioeconomic disadvantage did not explain differences in hazard of being diagnosed with infectious disease in secondary/tertiary care between children with immigrant versus Norwegian-born parents.
Collapse
Affiliation(s)
- Kjøllesdal M K R
- Division of Health Services, Norwegian Institute of Public Health, Norway
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Lifesciences, Norway
| | - Labberton A S
- Division of Health Services, Norwegian Institute of Public Health, Norway
| | - Reneflot A
- Division of Physical and Mental Health, Norwegian Institute of Public Health, Norway
| | - Qureshi S
- Division of Health Services, Norwegian Institute of Public Health, Norway
| | - Surén P
- Division of Physical and Mental Health, Norwegian Institute of Public Health, Norway
| |
Collapse
|
11
|
Almeida DQ, Barros H, Ribeiro AI. Residential and school green and blue spaces and intelligence in children: The Generation XXI birth cohort. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 813:151859. [PMID: 34826494 DOI: 10.1016/j.scitotenv.2021.151859] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 06/13/2023]
Abstract
Green and blue spaces have numerous health benefits. It has been hypothesized that contact with these spaces can have an important role in cognitive development, because it provides children with unique stimuli that can help develop curiosity, creativity, awareness, and control. This study aimed to estimate the association between exposure to green and blue spaces and the various measures of intelligence quotient (IQ) among children from Porto Metropolitan Area (Portugal). This investigation used data from the Generation XXI birth cohort. Exposure was assessed by Geographic Information Systems using vegetation indexes and measures of accessibility to urban green spaces and blue spaces in the surroundings of the residence and school, measured at 0, 4, 7 and 10 years. The outcome was the verbal, performance, and global IQ, measured using the Wechsler Intelligence Scale for Children (WISC-III), administered at age 10. Associations were estimated using crude and adjusted multilevel models. The mediation role of air pollution and physical activity was quantified. This study included 3827 children. The adjusted models showed that having green spaces up to 800 m of the residence was positively associated with performance IQ (1.30 95%CI [0.26; 2.35]) and global IQ (1.27 [0.18; 2.36]). No clear associations were observed regarding accessibility to blue spaces. Physical activity appeared to have a minor mediation role. Children with urban green spaces around their residences had higher performance and global IQ. Local actors in the sectors of public health and urban planning should promote the creation of green spaces close to residential areas.
Collapse
Affiliation(s)
- Diogo Queiroz Almeida
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, n° 135, 4050-600 Porto, Portugal; Unidade de Saúde Pública, Unidade Local de Saúde de Matosinhos, Rua de Alfredo Cunha 365, 4450-021 Matosinhos, Portugal.
| | - Henrique Barros
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, n° 135, 4050-600 Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas, n° 135, 4050-600 Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ana Isabel Ribeiro
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Rua das Taipas, n° 135, 4050-600 Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Rua das Taipas, n° 135, 4050-600 Porto, Portugal; Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| |
Collapse
|
12
|
Carrilero N, Dalmau-Bueno A, García-Altés A. Socioeconomic inequalities in 29 childhood diseases: evidence from a 1,500,000 children population retrospective study. BMC Public Health 2021; 21:1150. [PMID: 34130683 PMCID: PMC8205646 DOI: 10.1186/s12889-021-11230-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Socioeconomic position (SEP) powerfully affects health status in the childhood population. However, the knowledge of which diseases are more affected by SEP and whose outcomes could be improved by having a more equitable society remains uncertain on a population basis. METHODS We measured socioeconomic and gender inequalities in the pre-COVID-19 era for 29 diseases in the entire childhood population in Catalonia to identify which diseases are most impacted by inequalities. This population-based study included 1,449,816 children under 15 years old from 2014 to 2017 (48.52% girls) and each of their registered diagnoses within the Catalonia National Health System. We calculated frequency measures by SEP and their sex ratios for each disease. We estimated four regression-based inequality measures: slope index of inequality, relative index of inequality (RII), absolute population-attributable fraction, and population-attributable fraction. RESULTS Twenty-five of the 29 diseases examined showed SEP inequalities. The diseases with the greatest inequalities in both sexes were tuberculosis, obesity, adjustment and anxiety disorders, essential hypertension, poisoning, short gestation, low birth weight, foetal growth retardation and intrauterine hypoxia and birth asphyxia and trauma (RII ≥ 2.0); only food allergy showed the opposite pattern (RII < 1.0). Overall, 80,188 (7.80%) of the disease events in boys and 74,921 (8.88%) in girls would be avoided if all children had the same disease rate as those in the medium-high SEP group, with tuberculosis, intrauterine hypoxia and birth asphyxia and trauma, obesity, and short gestation, low birth weight, foetal growth retardation being those that could be reduced the most in relative terms, and dermatitis, injuries, acute bronquitis, and being overweight those that could be reduced the most in absolute terms. Girls present higher RII than boys for respiratory allergy, asthma, dermatitis, being overweight, and obesity (p < 0.05). In contrast, boys showed higher RII compared to girls only in congenital anomalies (p < 0.05). CONCLUSIONS Socioeconomic and gender inequalities are widely present in childhood health. This indicates that SEP plays a common role in their development although it varies in magnitude according to each disease. It is also a phenomenon that comprises all SEP groups in society. Action needs to be taken to ensure a fairer start in life in terms of health.
Collapse
Affiliation(s)
- Neus Carrilero
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Carrer de Roc Boronat, 81-95, 08005 Barcelona, Spain
- Universitat Pompeu Fabra. Department of Experimental and Health Sciences (DCEXS), Barcelona, Spain
- Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Albert Dalmau-Bueno
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Carrer de Roc Boronat, 81-95, 08005 Barcelona, Spain
| | - Anna García-Altés
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Carrer de Roc Boronat, 81-95, 08005 Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- Institut d’Investigació Biomèdica (IIB Sant Pau), Barcelona, Spain
| |
Collapse
|
13
|
Paciência I, Moreira A, Moreira C, Cavaleiro Rufo J, Sokhatska O, Rama T, Hoffimann E, Santos AC, Barros H, Ribeiro AI. Neighbourhood green and blue spaces and allergic sensitization in children: A longitudinal study based on repeated measures from the Generation XXI cohort. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 772:145394. [PMID: 33561602 DOI: 10.1016/j.scitotenv.2021.145394] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 06/12/2023]
Abstract
Evidence on the effect of natural environments on atopy in children is limited and inconsistent, disregarding the time-varying and cumulative exposures throughout the life course. To assess critical periods of exposure as well as the effect of longitudinal trajectories of exposure to green and blue spaces on the development of allergic sensitization in children at the age of 10 years. A longitudinal study was conducted involving 730 children enrolled in Generation XXI, a population-based birth cohort from the Porto Metropolitan Area (Portugal). Food and aeroallergens sensitization were evaluated at 10 years of age using Phadiatop Infant, Phadiatop fx1 and fx22 ImmunoCAP (Thermo Fisher Scientific, Uppsala, Sweden). Residential Normalized Difference Vegetation Index (NDVI) and distance to the nearest blue space (sea, river) were assessed using a Geographic Information System. Latent class linear mixed models were fitted to determine longitudinal trajectories of exposure. Associations were estimated using Cox proportional hazards regression models and expressed using hazard ratios (HR) and 95% confidence intervals (95% CI). Residing in neighbourhoods surrounded by more vegetation at 10 years, as well as lifetime exposure to a trajectory of higher levels of NDVI, were associated with a lower risk of allergic sensitization [HR (95% CI) = 0.095 (0.011, 0.823) and HR (95% CI) = 0.539 (0.301, 0.965), respectively]. Our findings support a role for both longitudinal, but particularly late-childhood, exposure to green spaces, in the prevention of allergic sensitization in children.
Collapse
Affiliation(s)
- Inês Paciência
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal.
| | - André Moreira
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Carla Moreira
- Cmat - Centre of Mathematics School of Sciences, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - João Cavaleiro Rufo
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Oksana Sokhatska
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Tiago Rama
- Serviço de Imunologia Básica e Clínica, Departamento de Patologia, Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Elaine Hoffimann
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal
| | - Ana Cristina Santos
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Henrique Barros
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Ana Isabel Ribeiro
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Rua das Taipas 135, 4050-600 Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| |
Collapse
|
14
|
Casey JA, Rudolph KE, Robinson SC, Bruxvoort K, Raphael E, Hong V, Pressman A, Morello-Frosch R, Wei RX, Tartof SY. Sociodemographic Inequalities in Urinary Tract Infection in 2 Large California Health Systems. Open Forum Infect Dis 2021; 8:ofab276. [PMID: 34189179 PMCID: PMC8231389 DOI: 10.1093/ofid/ofab276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background Urinary tract infection (UTI) accounts for a substantial portion of outpatient visits and antibiotic prescriptions in the United States. Few studies have considered sociodemographic factors including low socioeconomic status (SES)—which may increase residential crowding, inappropriate antibiotic prescribing, or comorbidities—as UTI or multidrug-resistant (MDR) UTI risk factors. Methods We used 2015–2017 electronic health record data from 2 California health care systems to assess whether 3 sociodemographic factors—use of Medicaid, use of an interpreter, and census tract–level deprivation—were associated with overall UTI or MDR UTI. UTIs resistant to ≥3 antibiotic classes were considered MDR. Results Analyses included 601 352 UTI cases, 1 303 455 controls, and 424 977 urinary Escherichia coli isolates from Kaiser Permanente Southern California (KPSC) and Sutter Health in Northern California. The MDR prevalence was 10.4% at KPSC and 12.8% at Sutter Health. All 3 sociodemographic factors (ie, use of Medicaid, using an interpreter, and community deprivation) were associated increased risk of MDR UTI. For example, using an interpreter was associated with a 36% (relative risk [RR], 1.36; 95% CI, 1.31 to 1.40) and 28% (RR, 1.28; 95% CI, 1.22 to 1.34) increased risk of MDR UTI at KPSC and Sutter Health, respectively, adjusted for SES and other potential confounding variables. The 3 sociodemographic factors were only weakly associated with UTI overall. Conclusions We found low SES and use of an interpreter to be novel risk factors for MDR UTI in the United States.
Collapse
Affiliation(s)
- Joan A Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
- Correspondence: Joan A. Casey, Columbia University Mailman School of Public Health, 722 W 168th St, Rm 1206, New York, NY 10032-3727 ()
| | - Kara E Rudolph
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Sarah C Robinson
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Katia Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eva Raphael
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Alice Pressman
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Rachel Morello-Frosch
- Department of Environmental Science, Policy and Management and School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Rong X Wei
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| |
Collapse
|