Comparing harm reduction and overdose response services between community-based and public health department syringe service programmes using a national cross-sectional survey.

Background: Syringe services programmes (SSPs) are an evidence-based strategy to reduce infectious diseases and deliver overdose prevention interventions for people who use drugs. They face regulatory, administrative, and funding barriers that limit their implementation in the US, though the federal government recently began providing funding to support these efforts. In this study we aim to understand whether the organisational characteristics of SSPs are associated with the provision of syringe and other overdose response strategies. Methods: We examine four outcomes using the National Survey of Syringe Services Programs (NSSSP) (N = 472): syringe distribution, naloxone distribution, fentanyl test strip (FTS) availability, and buprenorphine implementation. These outcomes are assessed across three organizational categories of SSPs-those operated by public health departments (DPH), community-based organizations (CBOs) with government funding, and CBOs without government funding-while adjusting for community-level confounders. Findings: The proportion of SSPs by organizational category was 36% DPH, 42% CBOs with government funding, and 22% CBOs without government funding. Adjusting for community-level differences, we found that CBO SSPs with government funding had significantly higher provision of all four syringe and overdose response services as compared to DPH SSPs and across three of the four services as compared to CBO SSPs without government funding. CBO SSPs without government funding still had significantly higher provision of three of the four services as compared to programmes maintained by the DPH. Interpretation: CBO SSPs have strong potential to expand overdose response services nationally, particularly if provided with sustained and adequate funding. Communities should aim to provide funding that does not hinder SSP innovation so they can remain flexible in responding to local needs. Funding: This study was supported by Arnold Ventures (20-05172).

Funding and Delivery of Syringe Services Programs in the United States, 2022.

Objectives. To describe the current financial health of syringe services programs (SSPs) in the United States and to assess the predictors of SSP budget levels and associations with delivery of public health interventions. Methods. We surveyed all known SSPs operating in the United States from February to June 2022 (n = 456), of which 68% responded (n = 311). We used general estimating equations to assess factors influencing SSP budget size and estimated the effects of budget size on multiple measures of SSP services. Results. The median SSP annual budget was $100 000 (interquartile range = $20 159‒$290 000). SSPs operating in urban counties and counties with higher levels of opioid overdose mortality had significantly higher budget levels, while SSPs located in counties with higher levels of Republican voting in 2020 had significantly lower budget levels. SSP budget levels were significantly and positively associated with syringe and naloxone distribution coverage. Conclusions. Current SSP funding levels do not meet minimum benchmarks. Increased funding would help SSPs meet community health needs. Public Health Implications. Federal, state, and local initiatives should prioritize sustained SSP funding to optimize their potential in addressing multiple public health crises. (Am J Public Health. 2024;114(4):435-443. https://doi.org/10.2105/AJPH.2024.307583).

Disentangling impacts of multiple pollutants on acute cardiovascular events in New York city: A case-crossover analysis.

BACKGROUND: Ambient air pollution contributes to an estimated 6.67 million deaths annually, and has been linked to cardiovascular disease (CVD), the leading cause of death. Short-term increases in air pollution have been associated with increased risk of CVD event, though relatively few studies have directly compared effects of multiple pollutants using fine-scale spatio-temporal data, thoroughly adjusting for co-pollutants and temperature, in an exhaustive citywide hospitals dataset, towards identifying key pollution sources within the urban environment to most reduce, and reduce disparities in, the leading cause of death worldwide. OBJECTIVES: We aimed to examine multiple pollutants against multiple CVD diagnoses, across lag days, in models adjusted for co-pollutants and meteorology, and inherently adjusted by design for non-time-varying individual and aggregate-level covariates, using fine-scale space-time exposure estimates, in an exhaustive dataset of emergency department visits and hospitalizations across an entire city, thereby capturing the full population-at-risk. METHODS: We used conditional logistic regression in a case-crossover design - inherently controlling for all confounders not varying within case month - to examine associations between spatio-temporal nitrogen dioxide (NO2), fine particulate matter (PM2.5), sulfur dioxide (SO2), and ozone (O3) in New York City, 2005-2011, on individual risk of acute CVD event (n = 837,523), by sub-diagnosis [ischemic heart disease (IHD), heart failure (HF), stroke, ischemic stroke, acute myocardial infarction]. RESULTS: We found significant same-day associations between NO2 and risk of overall CVD, IHD, and HF - and between PM2.5 and overall CVD or HF event risk - robust to all adjustments and multiple comparisons. Results were comparable by sex and race - though median age at CVD was 10 years younger for Black New Yorkers than White New Yorkers. Associations for NO2 were comparable for adults younger or older than 69 years, though PM2.5 associations were stronger among older adults. DISCUSSION: Our results indicate immediate, robust effects of combustion-related pollution on CVD risk, by sub-diagnosis. Though acute impacts differed minimally by age, sex, or race, the much younger age-at-event for Black New Yorkers calls attention to cumulative social susceptibility.

Neighborhood violence and socioeconomic deprivation influence associations between acute air pollution and temperature on childhood asthma in New York city.

Ambient air pollution, temperature, and social stressor exposures are linked with asthma risk, with potential synergistic effects. We examined associations for acute pollution and temperature exposures, with modification by neighborhood violent crime and socioeconomic deprivation, on asthma morbidity among children aged 5-17 years year-round in New York City. Using conditional logistic regression in a time-stratified, case-crossover design, we quantified percent excess risk of asthma event per 10-unit increase in daily, residence-specific exposures to PM2.5, NO2, SO2, O3, and minimum daily temperature (Tmin). Data on 145,834 asthma cases presenting to NYC emergency departments from 2005 to 2011 were obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Residence- and day-specific spatiotemporal exposures were assigned using the NYC Community Air Survey (NYCCAS) spatial data and daily EPA pollution and NOAA weather data. Point-level NYPD violent crime data for 2009 (study midpoint) was aggregated, and Socioeconomic Deprivation Index (SDI) scores assigned, by census tract. Separate models were fit for each pollutant or temperature exposure for lag days 0-6, controlling for co-exposures and humidity, and mutually-adjusted interactions (modification) by quintile of violent crime and SDI were assessed. We observed stronger main effects for PM2.5 and SO2 in the cold season on lag day 1 [4.90% (95% CI: 3.77-6.04) and 8.57% (5.99-11.21), respectively]; Tmin in the cold season on lag day 0 [2.26% (1.25-3.28)]; and NO2 and O3 in the warm season on lag days 1 [7.86% (6.66-9.07)] and 2 [4.75% (3.53-5.97)], respectively. Violence and SDI modified the main effects in a non-linear manner; contrary to hypotheses, we found stronger associations in lower-violence and -deprivation quintiles. At very high stressor exposures, although asthma exacerbations were highly prevalent, pollution effects were less apparent-suggesting potential saturation effects in socio-environmental synergism.

What Is "Socioeconomic Position (SEP)," and How Might It Modify Air Pollution-Health Associations? Cohering Findings, Identifying Challenges, and Disentangling Effects of SEP and Race in US City Settings.

PURPOSE OF REVIEW: Environmental epidemiology has long considered socioeconomic position (SEP) to be an important confounder of pollution effects on health, given that, in the USA, lower-income and minority communities are often disproportionately exposed to pollution. In recent decades, a growing literature has revealed that lower-SEP communities may also be more susceptible to pollution. Given the vast number of material and psychosocial stressors that vary by SEP, however, it is unclear which specific aspects of SEP may underlie this susceptibility. As environmental epidemiology engages more rigorously with issues of differential susceptibility, it is pertinent to define SEP more clearly, to disentangle its many aspects, and to move towards identifying causal components. Myriad stressors and exposures vary with SEP, with effects accumulating and interacting over the lifecourse. Here, we ask: In the context of environmental epidemiology, how do we meaningfully characterize"SEP"? RECENT FINDINGS: In answering this question, it is critical to acknowledge that SEP, stressors, and pollution are differentially distributed by race in US cities. These distributions have been shaped by neighborhood sorting and race-based residential segregation rooted in historical policies and processes (e.g., redlining), which have served to concentrate wealth and opportunities for education and employment in predominantly-white communities. As a result, it is now profoundly challenging to separate SEP from race in the urban US setting. Here, we cohere evidence from our recent and on-going studies aimed at disentangling synergistic health effects among SEP-related stressors and pollutants. We consider an array of SEP-linked social stressors, and discuss persistent challenges in this epidemiology, many of which are related to spatial confounding among multiple pollutants and stressors. Combining quantitative results with insights from qualitative data on neighborhood perceptions and stress (including violence and police-community relations), we offer a lens towards unpacking the complex interplay among SEP, community stressors, race, and pollution in US cities.

Air infiltration in low-income, urban homes and its relationship to lung function.

Previous research has found increased home ventilation, which may affect health by altering the composition of indoor air, is associated with improvement of respiratory health, but evidence linking home ventilation to objectively measured lung function is sparse. The Colorado Home Energy Efficiency and Respiratory health (CHEER) study, a cross-sectional study of low-income, urban, nonsmoking homes across the Northern Front Range of Colorado, USA, focused on elucidating this link. We used a multipoint depressurization blower door test to measure the air tightness of the homes and calculate the annual average infiltration rate (AAIR). Lung function tests were administered to eligible participants. We analyzed data from 253 participants in 187 homes with two or more acceptable spirometry tests. We used generalized estimating equations to model forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC z-scores as a function of AAIR. AAIRs ranged from 0.10 to 1.98 air changes per hour. Mean z-scores for FEV1, FVC, and FEV1/FVC were -0.57, 0.32, and -0.43, respectively. AAIR was positively associated with increased FEV1/FVC z-scores, such that a 1-unit change in AAIR corresponded to a half of a standard deviation in lung function (ß = 0.51, CI: 0.02-0.99). These associations were strongest for healthy populations and weaker for those with asthma and asthma-like symptoms. AAIR was not associated with FEV1 or FVC. Our study is the first in the United States to link home ventilation by infiltration to objectively measured lung function in low-income, urban households.

Putting Co-Exposures on Equal Footing: An Ecological Analysis of Same-Scale Measures of Air Pollution and Social Factors on Cardiovascular Disease in New York City.

Epidemiologic evidence consistently links urban air pollution exposures to health, even after adjustment for potential spatial confounding by socioeconomic position (SEP), given concerns that air pollution sources may be clustered in and around lower-SEP communities. SEP, however, is often measured with less spatial and temporal resolution than are air pollution exposures (i.e., census-tract socio-demographics vs. fine-scale spatio-temporal air pollution models). Although many questions remain regarding the most appropriate, meaningful scales for the measurement and evaluation of each type of exposure, we aimed to compare associations for multiple air pollutants and social factors against cardiovascular disease (CVD) event rates, with each exposure measured at equal spatial and temporal resolution. We found that, in multivariable census-tract-level models including both types of exposures, most pollutant-CVD associations were non-significant, while most social factors retained significance. Similarly, the magnitude of association was higher for an IQR-range difference in the social factors than in pollutant concentrations. We found that when offered equal spatial and temporal resolution, CVD was more strongly associated with social factors than with air pollutant exposures in census-tract-level analyses in New York City.

Impact of Outdoor Air Pollution on Indoor Air Quality in Low-Income Homes during Wildfire Seasons.

Indoor and outdoor number concentrations of fine particulate matter (PM2.5), black carbon (BC), carbon monoxide (CO), and nitrogen dioxide (NO2) were monitored continuously for two to seven days in 28 low-income homes in Denver, Colorado, during the 2016 and 2017 wildfire seasons. In the absence of indoor sources, all outdoor pollutant concentrations were higher than indoors except for CO. Results showed that long-range wildfire plumes elevated median indoor PM2.5 concentrations by up to 4.6 times higher than outdoors. BC, CO, and NO2 mass concentrations were higher indoors in homes closer to roadways compared to those further away. Four of the homes with mechanical ventilation systems had 18% higher indoor/outdoor (I/O) ratios of PM2.5 and 4% higher I/O ratios of BC compared to other homes. Homes with exhaust stove hoods had PM2.5 I/O ratios 49% less than the homes with recirculating hoods and 55% less than the homes with no stove hoods installed. Homes with windows open for more than 12 hours a day during sampling had indoor BC 2.4 times higher than homes with windows closed. This study provides evidence that long-range wildfire plumes, road proximity, and occupant behavior have a combined effect on indoor air quality in low-income homes.

Social and Environmental Neighborhood Typologies and Lung Function in a Low-Income, Urban Population.

Consensus is growing on the need to investigate the joint impact of neighborhood-level social factors and environmental hazards on respiratory health. This study used latent profile analysis (LPA) to empirically identify distinct neighborhood subtypes according to a clustering of social factors and environmental hazards, and to examine whether those subtypes are associated with lung function. The study included 182 low-income participants who were enrolled in the Colorado Home Energy Efficiency and Respiratory Health (CHEER) study during the years 2015⁻2017. Distinct neighborhood typologies were identified based on analyses of 632 census tracts in the Denver-Metro and Front Range area of Colorado; neighborhood characteristics used to identify typologies included green space, traffic-related air pollution, violent and property crime, racial/ethnic composition, and socioeconomic status (SES). Generalized estimating equations were used to examine the association between neighborhood typology and lung function. We found four distinct neighborhood typologies and provide evidence that these social and environmental aspects of neighborhoods cluster along lines of advantage/disadvantage. We provide suggestive evidence of a double jeopardy situation where low-income populations living in disadvantaged neighborhoods may have decreased lung function. Using LPA with social and environmental characteristics may help to identify meaningful neighborhood subtypes and inform research on the mechanisms by which neighborhoods influence health.

Spatio-temporal neighborhood impacts on internalizing and externalizing behaviors in U.S. elementary school children: Effect modification by child and family socio-demographics.

Increasing evidence from experimental and non-experimental research has shown that children residing in disadvantaged neighborhoods exhibit greater levels of internalizing and externalizing behaviors, above and beyond individual characteristics, and family or school contexts. Using the ECLS-K, a nationally representative, longitudinal survey of U.S. school children, this study examined direct neighborhood effects on internalizing (N = 14,870; N = 10,610) and externalizing (N = 14,960; N = 10,730) behaviors at the beginning and end of elementary school. Using IPTW propensity scores to mitigate selection bias and ordinary least squares regression, we examined direct neighborhood effects when children were 7 years old (1st grade) and when they were 11 years old (5th grade). We also examined neighborhood effect modification by child child race/ethnicity, sex, family structure, and family SES. Both the direct effect and effect modification models indicated that living in disadvantaged neighborhoods had no impact on either internalizing or externalizing behaviors at the beginning of elementary school (age 7). At the end of elementary school (age 11), we found small, yet significant direct neighborhood associations with effect sizes ranging from 0.12 to 0.18 standard deviations. The effect modification analysis revealed that being black (relative to white) was the strongest moderator of the relationship between neighborhood context and internalizing and externalizing behaviors in 5th grade, with effect sizes ranging from 0.27 to 0.59 standard deviations. Being Hispanic in high poverty neighborhoods was found to be protective for externalizing behaviors, suggesting the presence of the Hispanic health paradox. We also found, that in some neighborhood contexts, child sex, family structure, and family socioeconomic status amplified or dampened the effect of neighborhood, but only for externalizing behaviors. These results demonstrate the importance of age-dependent neighborhood effects and that children with different demographic profiles respond differently to the social contexts in which they are exposed.

Relevant social and spatial contexts for elementary school children: An examination of multiple scales.

This study examined direct area-level effects of 4 common child well-being outcomes across multiple scales of residential and school neighborhoods to identify relevant contexts for measuring neighborhood effects on elementary school children. Results from growth curve models indicate that neighborhoods operationalized as residential and school census tracts exerted similar effect sizes while neighborhoods operationalized as school attendance zones showed attenuated effects. These results suggest that it may be reasonable to interchange residential and school census tracts when examining contextual effects on child well-being. In addition, results suggest that school attendance zones represent conservative, theoretically sound neighborhoods for elementary school children.

Neighborhood racial composition and trajectories of child self-rated health: an application of longitudinal propensity scores.

Children function within multiple socio-environmental contexts including family, school, and neighborhood. The role each of these contexts play in determining well-being is dynamic and changes throughout early-middle childhood. Recent literature on neighborhood context and health suggests that the life-course processes involved in building trajectories of health are not adequately captured in cross-sectional analysis, which has been the empirical focus of much of the research in this area. In this study we use a nationally representative longitudinal sample of approximately 21,400 United States school children derived from the Early Childhood Longitudinal Study--Kindergarten Cohort (ECLS-K) survey to examine the impact of longitudinal measures of neighborhood racial composition on child self-rated health between kindergarten and 8th grade. We employ two-level multilevel longitudinal logistic regression models with time-varying propensity scores to examine variation in the initial status and trajectories of child self-rated health between kindergarten and 8th grade. Since the ECLS-K tracked child mobility over time, we are able to model the impact of changes in neighborhood racial composition. We find significant differences in initial poor self-rated health by child race, household socioeconomic status and parental marital status but no evidence of a change in trajectory of health over time. Using time-varying propensity scores, we find no effect of neighborhood racial composition on initial health status or health status trajectories.

The impact of childhood mobility on exposure to neighborhood socioeconomic context over time.

We used the 1998-1999 Early Childhood Longitudinal Study-Kindergarten Cohort, with data collected in kindergarten, first, third, fifth, and eighth grades, in a descriptive analysis of associations between early childhood residential mobility frequency and neighborhood context changes. We found that children who move frequently appear initially to move into higher-socioeconomic-status neighborhoods but eventually move back to lower-socioeconomic-status neighborhoods, exposing frequent movers to diverse neighborhood contexts. These findings have implications for policy and research that seeks to link neighborhood context to health.

Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care.

Dysphagia may predispose stroke patients toward undernutrition and hydration. These comorbidities increase patient risks for reduced functional outcome and short-term mortality. Despite this impact, available information on relationships among dysphagia, nutrition, and hydration status in acute stroke is limited and conflicted. This study evaluated nutrition and hydration status in ischemic stroke patients with versus without clinically significant dysphagia at admission and at discharge from acute care. Sixty-seven patients admitted to the stroke unit in a tertiary-care hospital provided data for this study. On the day of hospital admission and upon discharge or at 7 days post admission, serum biochemical measures were obtained for nutrition (prealbumin) and hydration status (BUN/Cr). Clinical evaluation for dysphagia, nutrition status, and stroke severity were completed an average of 1.4 days following hospital admission. Dysphagia was identified in 37 % of the cohort. At admission 32 % of patients demonstrated malnutrition based on prealbumin levels and 53 % demonstrated evidence of dehydration based on BUN/Cr levels. No differences in nutrition status were attributed to dysphagia. Patients with dysphagia demonstrated significantly higher BUN/Cr levels (greater dehydration) than patients without dysphagia at admission and at discharge. Dehydration at both admission and discharge was associated with dysphagia, clinical nutrition status, and stroke severity. Results of this study support prior results indicating that dysphagia is not associated with poor nutrition status during the first week post stroke. Dehydration status is associated with dysphagia during this period. The results have implications for future confirmatory research and for clinical management of dysphagia in the acute stroke period.

Prospective study of peer victimization and social-psychological adjustment in children with endocrine disorders.

This article evaluates the relations between peer victimization and child and parent reports of social-psychological variables 1.5 years later. Thirty-six children diagnosed with endocrine disorders and their parents completed questionnaires regarding social-psychological functioning. Peer victimization at time 2 was significantly related to concurrent depression, loneliness, externalizing and internalizing symptoms. Hierarchical linear regression equations indicated that peer victimization at baseline was not a significant predictor of time 2 social-psychological functioning when baseline levels of each variable were controlled. Significant correlations were found between baseline and time 2 levels of social anxiety, loneliness, externalizing and internalizing symptoms, with medium to large effect sizes. Peer victimization, social anxiety, loneliness, internalizing and externalizing behavior problems are relatively stable across time. Peer victimization is related to concurrent adjustment problems but may not contribute to the development of new problems. Early identification and intervention is imperative. Medical visits are an opportunity to assess and refer for treatment.

Peer victimization in children with attention-deficit hyperactivity disorder.

This study examined the correlation of peer victimization to psychosocial adjustment in a sample of children diagnosed with attention-deficit hyperactivity disorder (ADHD). A total of 303 files of youth who received a psycho-educational assessment were reviewed; of these, 116 had an ADHD diagnosis. The data collected included the Child Behavior Checklist (which includes items assessing peer victimization), Conner's Parent Rating Scale, Revised Children's Manifest Anxiety Scale and Children's Depression Inventory. Peer victimization was positively correlated with parent reports of anxiety, depression, social problems, delinquent behavior and aggressive behavior. Children with a comorbid psychiatric diagnosis with ADHD reported higher rates of peer victimization than those without a comorbid diagnosis. Children diagnosed with ADHD along with a comorbid externalizing psychiatric diagnosis experienced higher rates of peer victimization than those with a comorbid internalizing psychiatric diagnosis. The implications of this study concerning peer victimization and psychosocial adjustment in children with ADHD are discussed.