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

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

Structural Bias in the Completeness of Death Investigations for Sudden Unexpected Infant Deaths (SUIDs).

OBJECTIVE: To assess sudden unexpected infant death (SUID) investigations for structural inequities by race/ethnicity and geography. METHODS: The SUID Case Registry compiles data on death investigations. We analyzed cases from 2015 to 2018 (N = 3847) to examine likelihood of an incomplete death investigation, defined as missing autopsy, missing scene investigation, or missing detailed information about where and how the body was found. We also analyzed which specific components of death investigations led to the greatest number of incomplete investigations. RESULTS: Twenty-four percent of SUIDs had incomplete death investigations. Death scenes in rural places had 1.51 times the odds of incomplete death investigations (95% confidence interval [CI], 1.19-1.92) compared with urban areas. Scene investigations led by law enforcement were more likely to result in incomplete death investigations (odds ratio [OR] = 1.49; 95% CI, 1.18-1.88) than those led by medical examiners. American Indian/Alaska Native SUIDs were more likely than other racial groups to have an incomplete investigation (OR = 1.49; 95% CI, 0.92-2.42), more likely to occur in rural places ( P = .055), and more likely to be investigated by law enforcement ( P < .001). If doll reenactments had been performed, 358 additional cases would have had complete investigations, and if SUID investigation forms had been performed, 243 additional cases would have had complete investigations. American Indian/Alaska Native SUIDs were also more likely to be missing specific components of death investigations. CONCLUSION: To produce equitable public health surveillance data used in prevention efforts, it is crucial to improve SUID investigations, especially in rural areas and among American Indian/Alaska Native babies.

Ethnic Enclaves and Incidence of Cancer Among US Ethnic Minorities in the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Since immigrants and their descendants represent a growing proportion of the US population, there is a strong demographic imperative for scientists to better understand the cancer risk factors at multiple levels that exist for these populations. Understanding the upstream causes of cancer, including neighborhood context, may help prevention efforts. Residence in ethnic enclaves may be one such contextual cause; however, the evidence is mixed, and past research has not utilized prospective designs examining cancer incidence or mortality. METHODS: We examined the association between residency in ethnic enclaves and cancer events among Hispanic (n = 753) and Chinese (n = 451) participants without a history of cancer in the Multi-Ethnic Study of Atherosclerosis (MESA), a prospective cohort study that enrolled participants ages 45-84 in six US cities. Cancer events included deaths and hospitalization for any cancer diagnosis from 2000-2012. Residency in an ethnic enclave was operationalized as their geocoded baseline census tract having a concentration of residents of the same ethnicity greater than the 75th percentile (compared to non-ethnic enclave otherwise). Potential confounders were blocked into three categories: sociodemographic, acculturation, and biomedical/health behavior variables. To examine the association between ethnic enclaves and cancer, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards models. RESULTS: Among Hispanic participants, residing in ethnic enclaves (vs. not) was associated with a 39% reduction in cancer risk (HR 0.61, 95%CI: 0.31, 1.21) after adjusting for sociodemographic variables. Among Chinese participants, residing in ethnic enclaves was associated with a 2.8-fold increase in cancer risk (HR 2.86, 95%CI; 1.38, 5.94) after adjusting for sociodemographic variables. CONCLUSIONS: Our results suggest that the association between ethnic enclaves and cancer events differs by ethnic group, suggesting that different social and contextual factors may operate in different communities.

Family deaths in the early life course and their association with later educational attainment in a longitudinal cohort study.

Due to structural racism and pathways between racism and health, Black and Native American people die at younger ages than white people. This means that those groups are likely to experience deaths of family members at younger ages. Evidence is mixed about whether family deaths affect educational attainment. We aim to 1) estimate the prevalence of family deaths by age and race 2) estimate the effect of a family death on later educational attainment and 3) analyze whether the effect of a family death varies by age, socioeconomic status, gender, and race. The National Longitudinal Study of Adolescent to Adult Health (Add Health) is a nationally representative sample of U.S. adolescents in grades 7-12 at baseline in 1994-1995. Add Health has a large and racially diverse sample and records family deaths across the entire life course starting from birth. Participants were included in this analysis if they reported their educational attainment in Wave IV (N = 14,796). The racial group with the lowest proportion experiencing a sibling or parent death in the first 23 years of their lives was white participants (11.7%), followed by Asian (12.5%), Hispanic (15.0%), Black (24.3%) and Native American participants (30.3%). In adjusted models, those who experienced a family death had 0.60 times the odds (95% CI 0.51-0.71) of achieving a bachelor's degree compared to those without a family death. Mother deaths, father deaths, and sibling deaths were each harmful for obtaining a college degree and their effects were similar in magnitude. The age range when the effect of a family death was strongest was 10-13 years old (OR = 0.52 95% CI 0.40-0.67). The effect of a family death on college degree attainment did not vary by baseline parent education, participant sex, or race/ethnicity.

Health disparities among millennial veterans by sexual orientation.

The objective of this study was to examine sexual orientation-based disparities in six self-reported health outcomes among millennial aged military veterans. We collected data using The Millennial Veteran Health Study, a cross-sectional internet-based survey with extensive quality control measures. The survey was fielded April through December 2020 and targeted millennial aged veterans across the United States. A total of 680 eligible respondents completed the survey. We assessed six binary health outcomes: alcohol use, marijuana use, frequent chronic pain, opioid misuse, high psychological distress, and fair or poor health status. Using logistic regression adjusted for a range of demographic, socioeconomic, and military-based covariates, we find that bisexual veterans consistently report worse health than straight veterans for all six health outcomes tested. Results for gay or lesbian, compared to straight veterans, were less consistent. Sensitivity models with continuous outcomes, and stratified by gender, found similar results. These results have implications for improving the health of bisexual individuals, including addressing discrimination, belonging, and social identity, particularly in institutional settings that have traditionally heteronormative and masculine cultures such as the military.

Effects of Housing Vouchers on the Long-Term Exposure to Neighborhood Opportunity among Low-Income Families: The Moving to Opportunity Experiment.

Tenant-based rental assistance has received much attention as a tool to ameliorate American poverty and income segregation. We examined whether a tenant-based voucher program improves long-term exposure to neighborhood opportunity overall and across multiple domains-social/economic, educational, and health/environmental-among low-income families with children. We used data from the Moving to Opportunity (MTO) experiment (1994-2010) with a 10- to 15-year follow-up period and used an innovative and multidimensional measure of neighborhood opportunities for children. Compared with controls in public housing, MTO voucher recipients experienced improvement in neighborhood opportunity overall and across domains during the entire study period, with a larger treatment effect for families in the MTO voucher group who received supplementary housing counseling, than the Section 8 voucher group. Our results also suggests that effects of housing vouchers on neighborhood opportunity may not be uniform across subgroups. Results from model-based recursive partitioning for neighborhood opportunity identified several potential effect modifiers for housing vouchers, including study sites, health and developmental problems of household members, and having vehicle access.

Estimating the Long-Term Causal Effects of Attending Historically Black Colleges or Universities on Depressive Symptoms.

Racism is embedded in society, and higher education is an important structure for patterning economic and health outcomes. Historically Black Colleges and Universities (HBCUs) were founded on antiracism while predominantly White institutions (PWIs) were often founded on white supremacy. This contrast provides an opportunity to study the association between structural racism and health among Black Americans. We used the National Longitudinal Study of Adolescent to Adult Health (Add Health) to estimate the long-term causal effect of attending an HBCU (vs. PWI) on depressive symptoms among Black students in the United States from 1994-2018. While we found no overall association with attending an HBCU (vs. PWI) on depressive symptoms, we found that this association varied by baseline mental health and region, and across time. For example, among those who attended high school outside of the South, HBCU attendance was protective against depressive symptoms 7 years later, and the association was strongest for those with higher baseline depressive symptoms. We recommend equitable state and federal funding for HBCUs, and that PWIs implement and evaluate antiracist policies to improve mental health of Black students.

Economic Hardship and Violence: A Comparison of County-Level Economic Measures in the Prediction of Violence-Related Injury.

Economic hardship may lead to a wide range of negative outcomes, including violence. However, existing literature on economic hardship and violence is limited by reliance on official reports of violence and conflation of different measures of economic hardship. The goals of this study are to measure how violence-related injuries are associated with five measures of county-level economic shocks: unemployment rate, male mass layoffs, female mass layoffs, foreclosure rate, and unemployment rate change, measured cross-sectionally and by a 1-year lag. This study measures three subtypes of violence outcomes (child abuse, elder abuse, and intimate partner violence). Yearly county-level data were obtained on violence-related injuries and economic measures from 2005 to 2012 for all 87 counties in Minnesota. Negative binomial models were run regressing the case counts of each violence outcome at the county-year level on each economic indicator modeled individually, with population denominator offsets to yield incidence rate ratios. Crude models were run first, then county-level socio-demographic variables and year were added to each model, and finally fully-adjusted models were run including all socio-demographic variables plus all economic indicators simultaneously. In the fully-adjusted models, a county's higher foreclosure rate is the strongest and most consistently associated with an increase in all violence subtypes. Unemployment rate is the second strongest and most consistent economic risk factor for all violence subtypes. Lastly, there appears to be an impact of gender specific to economic impacts on child abuse; specifically, male mass-lay-offs were associated with increased rates while female mass-lay-offs were associated with decreased rates. Understanding the associations of different types of economic hardship with a range of violence outcomes can aid in developing more holistic prevention and intervention efforts.

Do Alcohol Outlets Mediate the Effects of the Moving to Opportunity Experiment on Adolescent Excessive Drinking? A Secondary Analysis of a Randomized Controlled Trial.

Background: Housing mobility impacts adolescent alcohol use, and the neighborhood built environment may impact this relationship. Methods: Moving to Opportunity (MTO) was a multi-site, three-arm, household-level experiment. MTO randomly assigned one of three treatment arms (1994-1997) allowing families living in public housing to (1) receive a voucher to be redeemed any neighborhood (2) receive a voucher to be redeemed in a neighborhood with less than 10% poverty (3) remain in public housing (control). MTO decreased girls' alcohol use, but increased boys' alcohol use. Treatment groups were pooled because they are similar conceptually and statistically on our primary outcome. Among youth aged 12-19 in 2001-2002 (N = 2829), we estimated controlled direct effects mediation of MTO treatment effects on youth with housing vouchers (N = 1950) vs. controls (N = 879) on past 30-day number of drinks per day on days drank, using gender-stratified Poisson regression. Mediators were density of on- and off-premises alcohol outlets per square mile at the families' census tract of residence in 1997. Results: Treatment group youth were randomized to live in 1997 census tracts with lower off-premises, but higher on-premises, outlet density. MTO treatment (vs. controls) decreased drinking for girls via alcohol outlet density, but only at higher levels of outlet density. Treatment was 18% more beneficial when girls moved to high density neighborhoods, compared to controls who stayed living in public housing in high density neighborhoods. Conclusion: Additional social processes unmeasured in the current study may play an important role in the alcohol use and other health risks for girls.

Housing mobility protects against alcohol use for children with socioemotional health vulnerabilities: An experimental design.

PURPOSE: Neighborhood context may influence alcohol use, but effects may be heterogeneous, and prior evidence is threatened by confounding. We leveraged a housing voucher experiment to test whether housing vouchers' effects on alcohol use differed for families of children with and without socioemotional health or socioeconomic vulnerabilities. TRIAL DESIGN: In the Moving to Opportunity (MTO) study, low-income families in public housing in five US cities were randomized in 1994 to 1998 to receive one of three treatments: (1) a housing voucher redeemable in a low-poverty neighborhood plus housing counseling, (2) a housing voucher without locational restriction, or (3) no voucher (control). Alcohol use was assessed 10 to 15 years later (2008 to 2010) in youth ages 13 to 20, N = 4600, and their mothers, N = 3200. METHODS: Using intention-to-treat covariate-adjusted regression models, we interacted MTO treatment with baseline socioemotional health vulnerabilities, testing modifiers of treatment on alcohol use. RESULTS: We found treatment effect modification by socioemotional factors. For youth, MTO voucher treatment, compared with controls, reduced the odds of ever drinking alcohol if youth had behavior problems (OR = 0.26, 95% CI [0.09, 0.72]) or problems at school (OR = 0.46, [0.26, 0.82]). MTO low-poverty treatment (vs. controls) also reduced the number of drinks if their health required special medicine/equipment (OR = 0.50 [0.32, 0.80]). Yet treatment effects were nonsignificant among youth without socioemotional vulnerabilities. Among mothers of children with learning problems, MTO voucher treatment (vs. controls) reduced past-month drinking (OR = 0.69 [0.47, 0.99]), but was harmful otherwise (OR = 1.22 [0.99, 1.45]). CONCLUSIONS: For low-income adolescents with special needs/socioemotional problems, housing vouchers protect against alcohol use.

Violence in the Great Recession.

Substantial evidence suggests that economic hardship causes violence. However, a large majority of this research relies on observational studies that use traditional violence surveillance systems that suffer from selection bias and over-represent vulnerable populations, such as people of color. To overcome limitations of prior work, we employed a quasi-experimental design to assess the impact of the Great Recession on explicit violence diagnoses (injuries identified to be caused by a violent event) and proxy violence diagnoses (injuries highly correlated with violence) for child maltreatment, intimate partner violence, elder abuse, and their combination. We used Minnesota hospital data (2004-2014), conducting a difference-in-differences analysis at the county level (n = 86) using linear regression to compare changes in violence rates from before the recession (2004-2007) to after the recession (2008-2014) in counties most affected by the recession, versus changes over the same time period in counties less affected by the recession. The findings suggested that the Great Recession had little or no impact on explicitly identified violence; however, it affected proxy-identified violence. Counties that were more highly affected by the Great Recession saw a greater increase in the average rate of proxy-identified child abuse, elder abuse, intimate partner violence, and combined violence when compared with less-affected counties.

Connecting past to present: Examining different approaches to linking historical redlining to present day health inequities.

In the 1930's, the Home Owner Loan Corporation (HOLC) drafted maps to quantify variation in real estate credit risk across US city neighborhoods. The letter grades and associated risk ratings assigned to neighborhoods discriminated against those with black, lower class, or immigrant residents and benefitted affluent white neighborhoods. An emerging literature has begun linking current individual and community health effects to government redlining, but each study faces the same measurement problem: HOLC graded area boundaries and neighborhood boundaries in present-day health datasets do not match. Previous studies have taken different approaches to classify present day neighborhoods (census tracts) in terms of historical HOLC grades. This study reviews these approaches, examines empirically how different classifications fare in terms of predictive validity, and derives a predictively optimal present-day neighborhood redlining classification for neighborhood and health research.

The Validity and Reliability of Retrospective Measures of Childhood Socioeconomic Status in the Health and Retirement Study: Evidence From the 1940 U.S. Census.

OBJECTIVES: Retrospective measures of childhood socioeconomic status (SES) in cohort studies of aging that first observe people late in life-such as the Health and Retirement Study (HRS)-are widely used. However, their measurement validity and reliability are unknown. We assess the reliability and validity of the HRS's retrospective measures of parental education and childhood family finances. METHODS: We use records for 6,343 HRS sample members who were children in 1940 that have been linked to records from the complete-count 1940 U.S. Census. We assess interrater reliability by comparing (a) retrospective reports of childhood SES collected from sample members in the 1992-2018 HRS to (b) prospective measures of parallel concepts collected from HRS sample members' parents in the 1940 Census. We assess predictive validity by comparing the results of analyses that model later-life outcomes as a function of childhood SES as measured both prospectively and retrospectively. RESULTS: Interrater reliabilities of retrospective measures of parental education are high; however, the same is not true of the retrospective measure of childhood family finances. Both retrospective and prospective measures of childhood SES are predictive of later-life outcomes, and with similar strengths and directions of associations for most outcomes. DISCUSSION: Researchers who rely on retrospective indicators of childhood SES from the HRS should be aware of their measurement properties. They are measured with error, and that error modestly attenuates estimates of their associations with later-life outcomes. However, prospective and retrospective measures of childhood SES have similar predictive validity. These findings should reassure researchers who rely on retrospective measures of childhood SES in the HRS and similarly designed surveys.

Measuring the Effect of Neighborhood Racial Segregation on Fetal Growth.

Prior studies of neighborhood racial segregation and intrauterine growth have not accounted for confounding factors in early life. We used the Life-Course Influences on Fetal Environment Study of births to Black women in metropolitan Detroit, 2009-2011, (N = 1,408) to examine whether health and social conditions in childhood and adulthood confound or modify the association of neighborhood segregation (addresses during pregnancy geocoded to census tract racial composition) and gestational age-adjusted birthweight. Before adjusting for covariates, women living in a predominantly (≥75%) Black neighborhood gave birth to 47.3 grams (95% CI: -99.0, 4.4) lighter infants, on average, compared with women living in <75% Black neighborhoods. This association was confounded by adulthood (age at delivery, parity, neighborhood deprivation) and childhood (parental education, neighborhood racial composition) factors and modified by adulthood socioeconomic position. These findings underscore the complex relationship between neighborhood racial segregation and birth outcomes, which would be enhanced through a life course framework.

Measuring the hidden burden of violence: use of explicit and proxy codes in Minnesota injury hospitalizations, 2004-2014.

PURPOSE: Commonly-used violence surveillance systems are biased towards certain populations due to overreporting or over-scrutinized. Hospital discharge data may offer a more representative view of violence, through use of proxy codes, i.e. diagnosis of injuries correlated with violence. The goals of this paper are to compare the trends in violence in Minnesota, and associations of county-level demographic characteristics with violence rates, measured through explicitly diagnosed violence and proxy codes. It is an exploration of how certain sub-populations are overrepresented in traditional surveillance systems. METHODS: Using Minnesota hospital discharge data linked with census data from 2004 to 2014, this study examined the distribution and time trends of explicit, proxy, and combined (proxy and explicit) codes for child abuse, intimate partner violence (IPV), and elder abuse. The associations between county-level risk factors (e.g., poverty) and county violence rates were estimated using negative binomial regression models with generalized estimation equations to account for clustering over time. RESULTS: The main finding was that the patterns of county-level violence differed depending on whether one used explicit or proxy codes. In particular, explicit codes suggested that child abuse and IPV trends were flat or decreased slightly from 2004 to 2014, while proxy codes suggested the opposite. Elder abuse increased during this timeframe for both explicit and proxy codes, but more dramatically when using proxy codes. In regard to the associations between county level characteristics and each violence subtype, previously identified county-level risk factors were more strongly related to explicitly-identified violence than to proxy-identified violence. Given the larger number of proxy-identified cases as compared with explicit-identified violence cases, the trends and associations of combined codes align more closely with proxy codes, especially for elder abuse and IPV. CONCLUSIONS: Violence surveillance utilizing hospital discharge data, and particularly proxy codes, may add important information that traditional surveillance misses. Most importantly, explicit and proxy codes indicate different associations with county sociodemographic characteristics. Future research should examine hospital discharge data for violence identification to validate proxy codes that can be utilized to help to identify the hidden burden of violence.

Neighborhood Socioeconomic Status and Quality of Kidney Care: Data From Electronic Health Records.

RATIONAL & OBJECTIVE: Electronic health records can be leveraged to assess quality-of-care measures in patients with chronic kidney disease (CKD). Neighborhood socioeconomic status could be a potential barrier to receiving appropriate evidence-based therapy and follow-up. We examined whether neighborhood socioeconomic status is independently associated with quality of care received by patients with CKD. STUDY DESIGN: Observational study using electronic health record data. SETTING & PARTICIPANTS: Retrospective study of patients seen at a health care system in the 7-county Minneapolis/St Paul area. EXPOSURES: Census tract socioeconomic status measures (wealth, income, and education). OUTCOMES: Indicators of CKD quality of care: (1) prescription for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patients with stage ≥ 3 CKD or stage 1 or 2 CKD with urinary albumin-creatinine ratio (UACR) > 300 mg/d, (2) UACR measurement among patients with laboratory-based CKD (estimated glomerular filtration rate < 60 mL/min/1.72 m2), and (3) CKD identified on the problem list or coded for at an encounter among patients with laboratory-based CKD. ANALYTIC APPROACH: Multilevel Poisson regression with robust error variance with a random intercept at the census tract level. RESULTS: Of the 16,776 patients who should be receiving an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 65% were prescribed these medications. Among patients with laboratory-based CKD (n = 25,097), UACR was measured in 27% and CKD was identified in the electronic health record in 55%. We found no independent association between any neighborhood socioeconomic status measures and CKD quality-of-care indicators. LIMITATIONS: 1 health care system and selection bias. CONCLUSIONS: We found no association of neighborhood socioeconomic status with quality of CKD care in our cohort. However, adherence to CKD guidelines is low, indicating an opportunity to improve care for all patients regardless of neighborhood socioeconomic status.

Neighborhood Socioeconomic Status, Health Insurance, and CKD Prevalence: Findings From a Large Health Care System.

RATIONAL & OBJECTIVE: Neighborhood socioeconomic status (SES) and health insurance status may be important upstream social determinants of chronic kidney disease (CKD), but their relationship remains unclear. The aim of this study was to determine whether neighborhood SES and individual-level health insurance status were independently associated with CKD prevalence. STUDY DESIGN: Observational study using electronic health records (EHRs). SETTING & PARTICIPANTS: EHRs of patients (n = 185,269) seen at a health care system in the 7-county Minneapolis/St Paul area (2017-2018). EXPOSURES: Census tract neighborhood SES measures (median value of owner-occupied housing units [wealth], percentage of residents aged >25 years with bachelor's degree or higher [education]) and individual-level health insurance status (aged <65 years: Medicaid vs other insurance; ≥65 years: Medicare vs Medicare and supplemental insurance plan) were obtained from the American Community Survey and EHR data. Neighborhood SES was operationalized into quartiles, comparing low (first quartile) versus high (fourth quartile) neighborhood SES. OUTCOMES: CKD prevalence: estimated glomerular filtration rate < 60 mL/min/1.73 m2 or proteinuria. ANALYTIC APPROACH: Multilevel Poisson regression with robust error variance with a random intercept at the census-tract level, adjusted for demographic and clinical covariates, was used to estimate the association between neighborhood SES, insurance, and CKD. RESULTS: Neighborhood SES and insurance were independently associated with CKD prevalence. In covariate-adjusted models, patients living in low versus high neighborhood SES had a higher CKD prevalence among both younger and older patients. For example, the prevalence ratios of CKD in low versus high neighborhood SES as defined by education among patients younger than 65 and 65 years and older were 1.11 (95% CI, 1.05-1.18) and 1.08 (95% CI, 1.04-1.12), respectively. Patients younger than 65 years receiving Medicaid had higher CKD prevalence versus those with other insurance (1.51 [95% CI, 1.43-1.6]). For patients 65 years and older, insurance was not associated with prevalence of CKD in the fully adjusted model. LIMITATIONS: One health care system and selection bias. CONCLUSIONS: Living in low neighborhood SES as defined by wealth and education and having Medicaid for patients younger than 65 years were associated with higher CKD prevalence.

Intimate partner violence and social connection among married women in rural Bangladesh.

BACKGROUND: Intimate partner violence (IPV) is high among married women in Bangladesh. Social isolation is a well-established correlate of women's exposure to IPV, but the role of such factors in low-income and middle-income countries is not well understood. In this study, we explore whether social connection is protective against IPV among married women in rural Bangladesh. METHODS: Data were drawn from a multistage, stratified, population-based longitudinal sample of 3355 married women in rural Bangladesh, who were surveyed on individual and contextual risk factors of IPV. Negative binomial regression models were used to estimate the association between three different domains of social connection (natal family contact, female companionship and instrumental social support), measured at baseline in 2013, and the risk of three different forms of IPV (psychological, physical and sexual), approximately 10 months later, adjusted for woman's level of education, spouse's level of education, level of household wealth, age and age of marriage. RESULTS: Adjusted models showed that instrumental social support was associated with a lower risk of past year psychological IPV (risk ratio (RR)=0.84, 95% CI 0.769 to 0.914), sexual IPV (RR=0.90, 95% CI 0.822 to 0.997) and physical IPV (RR=0.81, 95% CI 0.718 to 0.937). Natal family contact was also associated with a lower risk of each type of IPV, but not in a graded fashion. Less consistent associations were observed with female companionship. CONCLUSION: Our findings suggest that social connection, particularly in the form of instrumental support, may protect married women in rural Bangladesh from experiencing IPV.

Social norms and the association between intimate partner violence and depression in rural Bangladesh-a multilevel analysis.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent globally and associated with adverse mental health outcomes among women. In IPV-endemic contexts like Bangladesh, previous research has found no association between low levels of IPV and depression. Although IPV and attitudes justifying IPV against women are highly prevalent in this context, nothing is known about how related contextual norms affect associations between individual-level IPV exposure and depression. The present study examines if village-level IPV norms, characterized using village-level (Level 2) prevalence of a) IPV-justifying attitudes (injunctive norms) and b) physical IPV (descriptive norms), modifies the individual-level (Level 1) associations between the severity of recent IPV and major depressive episode (MDE) among women in rural Bangladesh. METHODS: Data were drawn from a nationally-representative sample consisting of 3290 women from 77 villages. Multilevel models tested cross-level interactions between village-level IPV norms and recently experienced individual-level IPV on the association with past 30-day MDE. RESULTS: The prevalence of IPV was 44.4% (range: 9.6-76.2% across villages) and attitudes justifying IPV ranged from 1.6% to 49.8% across villages. The prevalence of MDE was 16.8%. The risk of MDE at low levels of IPV severity (versus none) was greater in villages with the least tolerant attitudes toward IPV compared to villages where IPV was more normative, e.g., interaction RR = 1.42 (95% CI: 0.64, 3.15) for low physical IPV frequency and injunctive norms. CONCLUSIONS: The association between IPV and depression may be modified by contextual-level IPV norms, whereby it is exacerbated in low-normative contexts.

Neighborhood Socioeconomic Status and Identification of Patients With CKD Using Electronic Health Records.

RATIONALE & OBJECTIVE: Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN: Screening test analysis. SETTINGS & PARTICIPANTS: Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE: The first quartile of census tract SES (median value of owner-occupied housing units <$165,200; average household income <$35,935; percentage of residents >25 years of age with a bachelor's degree or higher <20.4%), hypertension, and diabetes. OUTCOMES: CKD (eGFR <60 mL/min/1.73 m2, or urinary albumin-creatinine ratio >30mg/g, or urinary protein-creatinine ratio >150mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH: Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS: CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%-67.2%), 61% (95% CI, 61.1%-61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%-60.4%), specificity was 73% (95% CI, 72.4%-72.7%), and NNS was 4. LIMITATIONS: One health care system and selection bias. CONCLUSIONS: Leveraging patients' addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.