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Background: Social determinants of health (SDOH) significantly influence health behaviors, including tobacco use among youth. Adversities such as perceived discrimination, perceived neighborhood stress, life trauma, and financial strain are stressors that may mediate the relationship between various SDOH and youth tobacco use. This study aims to investigate whether multidimensional adversities mediate the effects of SDOH on tobacco use among youth. Methods: Data from the Adolescent Brain Cognitive Development (ABCD) study were used to test our hypotheses. The sample included a diverse cohort of youth aged 9-10 years old followed until they were 15-16 years old. We examined the effects of baseline parental education, household income, neighborhood income, and family structure on subsequent youth tobacco use. Structural equation models were used to test if adversities (perceived discrimination, life trauma, financial strain) operate as potential mediators. Results: All ABCD participants were eligible for our analysis, regardless of race, ethnicity, or SDOHs (n = 11,878). The findings indicated that the effects of parental education, household income, neighborhood income, and family structure on youth tobacco use were partially mediated by adversities. Higher levels of parental education and household income were associated with lower tobacco use, and this relationship was weakened when accounting for adversities. Similarly, stable family structures and higher neighborhood income were linked to reduced tobacco use, with adversities playing a mediating role. Conclusions: Multidimensional adversities partially mediate the relationship between SDOH at baseline and subsequent youth tobacco use. Interventions aimed at reducing youth tobacco use should address both the social determinants and multiple adversities experienced by adolescents. Policies to improve the educational and economic situations of families, enhance neighborhood environments, and support stable family structures all reduce youth tobacco use, with lower exposure to adversities explaining this effect.

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BACKGROUND: Low neighborhood income is linked with increased hospitalizations for central line-associated bloodstream infections (CLABSIs) in pediatric short bowel syndrome (SBS). We assessed whether this relationship varies by hospital center. METHODS: We performed a retrospective cohort study using the Pediatric Health Information System (2018-2023) database for patients <18 years old with SBS (N = 1210) at 24 hospitals in the United States. Using 2015 US Census data, we determined the estimated median household income of each patient's zip code. Hospital-level neighborhood income was defined as the median of the estimated median household income among patients at each hospital. We applied an extension of Cox regression to assess risk for CLABSI hospitalization. RESULTS: Among 1210 children with 5255 hospitalizations, most were <1 year on initial admission (53%), male (58%), and publicly insured (69%). Hospitals serving low-income neighborhoods served more female (46% vs 39%), Black (29% vs 22%), and Hispanic (22% vs 16%) patients with public insurance (72% vs 65%) residing in the southern United States (47% vs 21%). In univariate analysis, low hospital-level neighborhood income was associated with increased risk of CLABSI hospitalization (rate ratio [RR], 1.48; 95% CI, 1.21-1.83; P < 0.001). These findings persisted in multivariate analysis (RR, 1.43; 95% CI, 1.10-1.84; P < 0.01) after adjusting for race, ethnicity, insurance, region, and patient-level neighborhood income. CONCLUSION: Hospitals serving predominantly low-income neighborhoods bear a heavier burden of CLABSI hospitalizations for all their patients across the socioeconomic spectrum. Hospital initiatives focused on CLABSI prevention may be pivotal in addressing this disparity.

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Early pubertal timing is associated with youth mental health problems, with association amplified or mitigated by characteristics of the residential neighborhood. Yet, limited research simultaneously examines the roles of neighborhood context and biological sex in this association. This study fills this research gap by examining sex-specific associations between pubertal timing and neighborhood income with youth mental health problems (internalizing and externalizing symptoms) in a longitudinal cohort of early adolescents in the United States (US). Participants were 9201 youth aged 9 or 10 years from the Adolescent Brain Cognitive Development Study. Pubertal timing was the average of parent- and youth-reported pubertal status standardized within sex and age. Outcome variables were youths' internalizing and externalizing symptoms assessed at 1-year follow-up via parent survey. We evaluated interaction effects between pubertal timing and neighborhood income in a series of sex-stratified linear mixed effect models, adjusted for family and personal sociodemographic characteristics. In girls, earlier pubertal timing was associated with more internalizing (ß = 0.06, p < 0.001) and externalizing problems (ß = 0.07, p < 0.001) at 1-year follow-up, not moderated by neighborhood income. In boys, earlier pubertal timing was associated with more externalizing problems among youth living in high-income neighborhoods, but not among those in low-income neighborhoods (interaction-p = 0.006). Results suggest that pubertal timing may affect youth mental health differentially in boys and girls, depending on the neighborhood contexts. These findings highlight the importance of both biological and social forces in shaping adolescent mental health and, thus, have public health and clinical implications for health promotion.

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OBJECTIVE: We aim to investigate whether the availability of over-the-counter EC varies by neighborhood income level, independent vs chain pharmacies, or urban vs rural pharmacies. STUDY DESIGN: We conducted a cross-sectional "mystery shopper" telephone survey in July 2019 to ascertain whether sampled pharmacies stocked EC. Pharmacies located in 12 Pennsylvania counties were randomly sampled after stratification by neighborhood income level. RESULTS: Of 200 pharmacies sampled, 195 responded. Only 76% had EC available for same day purchase, which did not differ by neighborhood-level income. The odds that chain pharmacies stocked EC were nearly 10 times the odds that independent pharmacies stocked EC, with 96/105 chain pharmacies versus 52/90 independent pharmacies having EC available for same day purchase (91% vs 58%; OR 9.50, 95% CI 4.03-22.42). The mean number of barriers (stocking over-the-counter EC behind-the-counter, cost >$40, and requiring identification for purchase) was lower among chain vs. independent pharmacies. Pharmacies in low/moderate-income areas (64% vs 44%, p = 0.02) and independent pharmacies (94% vs 32%, p < 0.01) were more likely to keep over-the-counter EC behind-the-counter. Independent pharmacies were more likely to require identification for purchase (29% vs 59%, p < 0.01). CONCLUSION: More than a decade after over-the-counter approval, EC is still not uniformly available at pharmacies in Pennsylvania. Barriers including behind-the-counter stocking and identification requirements disproportionally limit access in low-income neighborhoods and independent pharmacies, threatening equitable access to this contraceptive method. IMPLICATION: Pharmacies in lower-income neighborhoods and independent pharmacies were more likely to impose undue barriers to EC access and purchasing, disproportionally affecting residents in lower-income areas. A multidisciplinary approach in advocacy and policy reform is necessary to ensure equitable access to EC.

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OBJECTIVES/HYPOTHESIS: Patients with cleft lip and/or palate (CLP) are at increased risk of malnutrition. Acute and chronic malnutrition have been associated with elevated risk of postsurgical wound complications, adding morbidity and cost to patients and their families. To study the association between demographic factors, including insurance type, race, and median neighborhood income (MNI), and malnutrition in patients with CLP. STUDY DESIGN: Retrospective cohort study. METHODS: Retrospective review was performed in patients undergoing their first cleft-related surgery at a large tertiary pediatric hospital from 2006 to 2018. Demographic data, weight and height at surgery, type of insurance, race, and primary residential address were collected. Geocoded information on MNI was generated using patient address. World Health Organization Z-scores for weight-for-age (WFA) and height-for-age (HFA) were used as proxies for acute and chronic malnutrition, respectively. Linear regression models were generated to analyze the relationship of insurance type, race, and MNI on WFA and HFA Z-scores. RESULTS: About 313 patients met inclusion criteria. Increasing MNI predicted increasing WFA Z-score (0.05 increase in WFA per $1,000 increase, P = .047) as well as HFA Z-score (0.09 increase in HFA per $1,000 increase, P = .011). The effect of MNI was not independently modified by race for either WFA (P = .841) nor HFA (P = .404). Race and insurance type did not predict WFA or HFA. CONCLUSIONS: Lower MNI is a significant independent risk factor for acute and chronic malnutrition in children with CLP. Combined with previous investigation linking malnutrition to surgical outcomes in this population, this offers a target area for intervention to improve patient outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1482-1486, 2022.

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INTRODUCTION: Contextual factors representing chronic stressors, such as neighborhood crime characteristics, have been repeatedly linked to compromised mental and physical health, and may contribute to the pathologizing of normative/non-clinical experiences. However, the impact of such structural factors has seldom been incorporated in Clinical High Risk (CHR) for psychosis research. Understanding how context can influence the presence or severity of symptoms such as suspiciousness/paranoia may have important relevance for promoting valid and reliable assessment, as well as for understanding ways in which environment may be related to illness development and expression. METHODS: A total of 126 adolescents and young adults (nCHR = 63, ncontrol = 63) underwent clinical interviews for Clinical High-Risk syndromes. Neighborhood crime indices and socioeconomic status were calculated through geocoding and extracting of publicly available Census and Federal Bureau of Investigation (FBI) data. Analyses examined presence of associations between neighborhood crime indices, socioeconomic status, suspiciousness and total symptoms. RESULTS: Greater neighborhood crime was related to increased suspiciousness in CHR individuals, even after controlling for neighborhood socioeconomic status, r = 0.27, p = .03. Neighborhood crime was not related to total symptoms, and neither was neighborhood socioeconomic status. DISCUSSION: Results suggest neighborhood crime uniquely related to suspiciousness symptoms in CHR individuals, while this was not the case for healthy volunteers (HV). Future work will be critical for determining the extent to which assessors are pathologizing experiences that are normative for a particular context, or rather, if a stressful context is serving as a sufficient environmental stressor to unmask emerging psychosis.

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Objectives To determine whether affluent-born White mother's descending neighborhood income is associated with infant mortality rates (< 365 day, IMR). Methods Stratified and multilevel logistic regression analyses were completed on the Illinois transgenerational dataset of singleton births (1989-1991) to non-Latina White mothers (1956-1976) with an early-life residence in affluent neighborhoods (defined as the fourth quartile of income distribution). The breadth of descending neighborhood income was defined by mother's neighborhood income at the time of delivery. Results Infants of White mothers (n = 4890) who did not suffer descending neighborhood income by the time of delivery had a first-year mortality rate of 5.1/1,000. Infants of White mothers who experienced minor (n = 5112), modest (n = 2158), or extreme (n = 339) descending neighborhood income had IMR of 6.5/1,000, 14.4/1,000, and 11.8/1,000, respectively; RR [95% CI] = 1.3 [0.8, 2.1], 2.8 [1.7, 4.8], and 2.3 [0.8, 6.6], respectively. The incidence of young maternal age, inadequate prenatal care utilization, and cigarette smoking rose as descending neighborhood income increased, p < 0.01. In multilevel logistic regression models, the adjusted (controlling for selected individual-level co-variates) OR [95% CI] of infant mortality for White women with an early-life residence in affluent neighborhoods who subsequently experienced minor or modest to extreme (versus absent) descending neighborhood income equaled 1.0 [0.6, 1.8] and 2.1 [1.1, 3.8] respectively. Conclusions White mother's modest to extreme descending neighborhood income from early-life residence in affluent neighborhoods is associated with a twofold greater risk of infant mortality independent of selected biologic, medical, and behavioral characteristics.

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Prior studies suggest that exposure to the natural environment may be important for optimal mental health. The present study examines the association between block-level greenness (vegetative presence) and mental health outcomes, in a population-based sample of 249,405 U.S. Medicare beneficiaries aged ≥65 years living in Miami-Dade County, Florida, USA, whose location did not change from 2010 to 2011. Multilevel analyses examined relationships between greenness, as measured by mean Normalized Difference Vegetation Index from satellite imagery at the Census block level, and each of two mental health outcomes; Alzheimer's disease and depression, respectively, after statistically adjusting for age, gender, race/ethnicity, and neighborhood income level of the individuals. Higher block-level greenness was linked to better mental health outcomes: There was a reduced risk of Alzheimer's disease (by 18%) and depression (by 28%) for beneficiaries living in blocks that were 1 SD above the mean for greenness, as compared to blocks that were 1 SD below the mean. Planned post-hoc analyses revealed that higher levels of greenness were associated with even greater mental health benefits in low-income neighborhoods: An increase in greenness from 1 SD below to 1 SD above the mean was associated with 37% lower odds of depression in low-income neighborhoods, compared to 27% and 21% lower odds of depression in medium- and high-income neighborhoods, respectively. Greenness may be effective in promoting mental health in older adults, particularly in low-income neighborhoods, possibly as a result of the increased opportunities for physical activity, social interaction, or stress mitigation.

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AIM: To determine factors associated with home death in patients with cancer in Ontario, particularly to assess the association between death at home and (1) patients' rural/urban residence and (2) neighborhood income in urban areas. MATERIALS AND METHODS: We conducted a retrospective cross-sectional study in Ontario (2003-2010) using linked administrative databases. In order to account for clustering phenomenon, multivariable generalized estimating equation model was used to evaluate factors associated with home death. Analysis was performed in both rural and urban areas. For urban areas, neighborhood income was tested as a determinant of the place of death. RESULTS: A total of 193 783 deaths were analyzed, 9.1% of which occurred at home. In urban areas, home death was more likely for patients living in richer neighborhoods (odds ratio 1.69 for the highest compared to lowest neighborhood income quintile, 95% confidence interval: 1.54-1.86). The odds of dying at home when living in a rural area were no different from those living in the poorest urban neighborhood. Other variables associated with lower odds of home death were comorbidity index, certain cancers, and year of death. CONCLUSION: The likelihood of dying at home significantly increases with living in higher-income urban neighborhoods and decreases with rural residence. Urban neighborhoods with lowest income have odds of home death similar to rural areas. These findings underline the importance of targeting proper populations for public support at the end of life.

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Less than half of young children in the U.S. meet physical activity recommendations. While neighborhood economic context has been shown to be associated with physical activity, it is unknown whether this association varies according to family economic context. This study thus investigates whether neighborhood economic context, measured by poverty concentration and income inequality, are associated with physical activity among poor and non-poor children using data from the Geographic Research on Wellbeing study, California, 2012-2013 (N=2670). Poor children who resided in (a) poor and equal neighborhoods or (b) non-poor and equal neighborhoods were more likely to engage in sufficient physical activity than were children residing in non-poor and unequal neighborhoods. Poor children in (a) non-poor and equal neighborhoods, (b) poor and equal neighborhoods, or (c) poor and unequal neighborhoods were less likely to report insufficient physical activity than those in non-poor and unequal neighborhoods. Neighborhood economic context was not associated with physical activity among non-poor children. Findings suggest that neighborhood economic context presents a social barrier to physical activity among poor children. Increasing physical activity among poor children in non-poor and unequal neighborhoods should be a high policy priority. Perceived social cohesion, perceived neighborhood safety, and park and walkability indicators did not mediate the associations between neighborhood economic context and physical activity. Further research needs to explore the mechanisms by which neighborhood economic context affects physical activity among children.

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Higher income neighborhoods are associated with better health, a relation observed in many cross-sectional studies. However, prior research focused on the prevalence of health conditions, and examining the incidence of new health conditions may provide stronger support for a potential causal role of neighborhoods on health. We used the 2004 and 2014 waves of the Midlife in the United States Study (n = 1726; ages 34-83) to examine health condition incidence as a function of neighborhood income. Among participants who had lived in the same neighborhood across the time period, we hypothesized that higher neighborhood income would be associated with a lower incidence of health conditions ten years later. Health included 18 chronic conditions related to mental (anxiety, depression) and physical (cardiovascular, immune) health. Multinomial logistic regression analyses adjusting for individual income and sociodemographics indicated that the odds of developing two or more new health conditions (no new health conditions as referent), was significantly lower (OR = 0.92, CI: 0.86, 0.99) for every $10,000 increment in neighborhood income. Associations did not vary by age or neighborhood tenure. Results add to a literature documenting that higher neighborhood income is associated with better health.

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Theory holds that income inequality may harm adolescent mental health by reducing social capital within neighborhood communities. However, research on this topic has been very limited. We use multilevel data on 102 public schools and 5958 adolescents in Iceland (15 and 16 years old) to examine whether income inequality within neighborhoods is associated with emotional distress in adolescents. Moreover, we test whether indicators of social capital, including social trust and embeddedness in neighborhood social networks, mediate this contextual effect. The findings show that neighborhood income inequality positively influences emotional distress of individual adolescents, net of their personal household situations and social relations. However, although the indicators of social capital negatively influence emotional distress, they do not mediate the contextual effect of neighborhood income inequality. The study illustrates the role of economic disparities in adolescent mental health, but calls for more research on the underlying social and social-psychological mechanisms.

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UNLABELLED: Objectives We investigated the contributions of cigarette smoking to the age-related patterns of preterm (<37 weeks) birth (PTB) rates among African-American and White women within the context of lifelong neighborhood income. Methods Stratified and multilevel logistic regression analyses were performed on an Illinois transgenerational dataset of non-Hispanic White and African-American infants (1989-1991) and their mothers (1956-1976) with appended US census income information. RESULTS: Among non-smoking African-American women (n = 20,107) with a lifelong residence in lower income neighborhoods, PTB rates decreased from 18.5 % for teens to 15.0 % for 30-35 year-olds, p < 0.0001. The opposite pattern occurred among African-American women smokers (n = 5936) with a lifelong residence in lower income neighborhoods, p < 0.01. Among upwardly mobile African-American women smokers (n = 756), PTB rates increased from 11.1 % for teens to 24.9 % for 30-35 year-olds, p < 0.05. Cigarette smoking was not associated with an age-related increase in PTB rates among African-American women with a lifelong residence in upper income neighborhoods. No subgroup of White women, even cigarette smokers with a lifelong residence in lower income neighborhoods, exhibited weathering with regard to PTB. Conclusions A weathering pattern of rising PTB rates with advancing age occurs only among African-American women cigarette smokers with an early-life or lifelong residence in lower income neighborhoods, underscoring the public health policy importance of targeted smoking cessation programs in eliminating the racial disparity in the age-related patterns of PTB rates.

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RATIONALE: The cost of continuous positive airway pressure (CPAP) treatment for patients with low socioeconomic status may be an important barrier to successful treatment of obstructive sleep apnea under a copayment health care system. OBJECTIVES: We evaluated an association between patient neighborhood income level and the purchase of a CPAP device under a cost-sharing health care insurance system. METHODS: All adults who underwent a first diagnostic sleep study at St. Michael's Hospital (Toronto, ON, Canada) between 2004 and 2010 were included. Severity of obstructive sleep apnea was determined by the apnea-hypopnea index (AHI) and level of daytime sleepiness (by the Epworth Sleepiness Scale). Patient data were linked to provincial health administrative data from 1991 to 2013 to determine the purchase of CPAP equipment, comorbidities, neighborhood income, and rural status at baseline. Neighborhood income was categorized into quintiles, ranked from poorest (Q1) to wealthiest (Q5). Assuming that the majority of participants with severe obstructive sleep apnea (AHI > 30 events/h) and excessive daytime sleepiness (Epworth Sleepiness Scale ≥ 10) would have been strongly recommended CPAP, we evaluated the association between patient neighborhood income and purchase of a CPAP device in this group via multivariable Cox regressions. MEASUREMENTS AND MAIN RESULTS: Of the 695 participants with severe obstructive sleep apnea and excessive daytime sleepiness, 400 (58%) purchased a CPAP device. Patients who accepted CPAP were more likely to live in a higher-income neighborhood. Cumulative incidence of CPAP acceptance at 6 months was 43% for individuals in a low-income neighborhood (Q1) and 52% in combined higher-income neighborhoods (Q2-5) (P = 0.05). Controlling for sex and age, living in higher-income neighborhoods was associated with a 27% increased chance of accepting CPAP compared with the lowest-income neighborhood (hazard ratio Q2-5 vs. Q1, 1.27; 95% confidence interval, 0.98-1.64; P = 0.07). CONCLUSIONS: Living in an unfavorable neighborhood is not an obstacle to CPAP treatment among symptomatic patients with severe obstructive sleep apnea under a copayment health care system. However, a potential 27% improvement in CPAP acceptance associated with higher neighborhood income is not inconsequential. Also, the overall CPAP acceptance rate was relatively low, suggesting that obstacles other than finances are primarily responsible.

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