Evaluating Methods for Mapping Historical Redlining to Census Tracts for Health Equity Research.

Neighborhood characteristics including housing status can profoundly influence health. Recently, increasing attention has been paid to present-day impacts of "redlining," or historic area classifications that indicated less desirable (redlined) areas subject to decreased investment. Scholarship of redlining and health is emerging; limited guidance exists regarding optimal approaches to measuring historic redlining in studies of present-day health outcomes. We evaluated how different redlining approaches (map alignment methods) influence associations between redlining and health outcomes. We first identified 11 existing redlining map alignment methods and their 37 logical extensions, then merged these 48 map alignment methods with census tract life expectancy data to construct 9696 linear models of each method and life expectancy for all 202 redlined cities. We evaluated each model's statistical significance and R2 values and compared changes between historical and contemporary geographies and populations using Root Mean Squared Error (RMSE). RMSE peaked with a normal distribution at 0.175, indicating persistent difference between historical and contemporary geographies and populations. Continuous methods with low thresholds provided higher neighborhood coverage. Weighting methods had more significant associations, while high threshold methods had higher R2 values. In light of these findings, we recommend continuous methods that consider contemporary population distributions and mapping overlap for studies of redlining and health. We developed an R application {holcmapr} to enable map alignment method comparison and easier method selection.

Resource Savings Associated With Use of an Automated Symptom Monitoring Tool for COVID-19 Public Health Response, Summer 2020-Summer 2021.

CONTEXT: Active symptom monitoring is a key component of the public health response to COVID-19, but these activities are resource-intensive. Digital tools can help reduce the burden of staff time required for active symptom monitoring by automating routine outreach activities. PROGRAM: Sara Alert is an open-source, Web-based automated symptom monitoring tool launched in April 2020 to support state, tribal, local, and territorial jurisdictions in their symptom monitoring efforts. IMPLEMENTATION: As of October 2021, a total of 23 public health jurisdictions in the United States had used Sara Alert to perform daily symptom monitoring for more than 6.1 million individuals. This analysis estimates staff time and cost saved in 3 jurisdictions that used Sara Alert as part of their COVID-19 response, across 2 use cases: monitoring of close contacts exposed to COVID-19 (Arkansas; Fairfax County, Virginia), and traveler monitoring (Puerto Rico). EVALUATION: A model-based approach was used to estimate the additional staff resources that would have been required to perform the active symptom monitoring automated by Sara Alert, if monitoring instead relied on traditional methods such as telephone outreach. Arkansas monitored 283 705 individuals over a 10-month study period, generating estimated savings of 61.9 to 100.6 full-time equivalent (FTE) staff, or $2 798 922 to $4 548 249. Fairfax County monitored 63 989 individuals over a 13-month study period, for an estimated savings of 24.8 to 41.4 FTEs, or $2 826 939 to $4 711 566. In Puerto Rico, where Sara Alert was used to monitor 2 631 306 travelers over the 11-month study period, estimated resource savings were 849 to 1698 FTEs, or $26 243 161 to $52 486 322. DISCUSSION: Automated symptom monitoring helped reduce the staff time required for active symptom monitoring activities. Jurisdictions reported that this efficiency supported a rapid and comprehensive COVID-19 response even when experiencing challenges with quickly scaling up their public health workforce.

Heat-Associated Mortality in a Hot Climate : Maricopa County, Arizona, 2006-2016.

OBJECTIVES: Maricopa County, Arizona (2017 population about 4.3 million), is located in the Sonoran Desert. In 2005, the Maricopa County Department of Public Health (MCDPH) established a heat-associated mortality surveillance system that captures data on circumstances of death for Maricopa County residents and visitors. We analyzed 2006-2016 surveillance system data to understand the characteristics and circumstances of heat-associated deaths. METHODS: We classified heat-associated deaths based on International Classification of Diseases, Tenth Revision codes (X30, T67.X, and P81.0) and phrases (heat exposure, environ, exhaustion, sun, heat stress, heat stroke, or hyperthermia) in part I or part II of the death certificate. We summarized data on decedents' demographic characteristics, years lived in Arizona, location of death (indoors vs outdoors), presence and functionality of air conditioning, and whether the decedent had been homeless. We examined significant associations between variables by using the Pearson χ2 tests and logistic regression. RESULTS: During 2006-2016, MCDPH recorded data on 920 heat-associated deaths, 912 of which included location of injury. Of 565 (62%) heat-associated deaths that occurred outdoors, 458 (81%) were among male decedents and 243 (43%) were among decedents aged 20-49. Of 347 (38%) heat-associated deaths that occurred indoors, 201 (58%) were among decedents aged ≥65. Non-Arizona residents were 5 times as likely as Arizona residents to have a heat-associated death outdoors (P < .001). Of 727 decedents with data on duration of Arizona residency, 438 (60%) had resided in Arizona ≥20 years. CONCLUSIONS: Ongoing evaluation of interventions that target populations at risk for both outdoor and indoor heat-associated deaths can further inform refinement of the surveillance system and identify best practices to prevent heat-associated deaths.

Initial and Repeated Point Prevalence Surveys to Inform SARS-CoV-2 Infection Prevention in 26 Skilled Nursing Facilities - Detroit, Michigan, March-May 2020.

Skilled nursing facilities (SNFs) are focal points of the coronavirus disease 2019 (COVID-19) pandemic, and asymptomatic infections with SARS-CoV-2, the virus that causes COVID-19, among SNF residents and health care personnel have been described (1-3). Repeated point prevalence surveys (serial testing of all residents and health care personnel at a health care facility irrespective of symptoms) have been used to identify asymptomatic infections and have reduced SARS-CoV-2 transmission during SNF outbreaks (1,3). During March 2020, the Detroit Health Department and area hospitals detected a sharp increase in COVID-19 diagnoses, hospitalizations, and associated deaths among SNF residents. The Detroit Health Department collaborated with local government, academic, and health care system partners and a CDC field team to rapidly expand SARS-CoV-2 testing and implement infection prevention and control (IPC) activities in all Detroit-area SNFs. During March 7-May 8, among 2,773 residents of 26 Detroit SNFs, 1,207 laboratory-confirmed cases of COVID-19 were identified during three periods: before (March 7-April 7) and after two point prevalence surveys (April 8-25 and April 30-May 8): the overall attack rate was 44%. Within 21 days of receiving their first positive test results, 446 (37%) of 1,207 COVID-19 patients were hospitalized, and 287 (24%) died. Among facilities participating in both surveys (n = 12), the percentage of positive test results declined from 35% to 18%. Repeated point prevalence surveys in SNFs identified asymptomatic COVID-19 cases, informed cohorting and IPC practices aimed at reducing transmission, and guided prioritization of health department resources for facilities experiencing high levels of SARS-CoV-2 transmission. With the increased availability of SARS-CoV-2 testing, repeated point prevalence surveys and enhanced and expanded IPC support should be standard tools for interrupting and preventing COVID-19 outbreaks in SNFs.

Factors Associated with Breastfeeding Initiation and Continuation: A Meta-Analysis.

OBJECTIVE: To use a quantitative approach to evaluate the literature for quantity, quality, and consistency of studies of maternal and infant characteristics in association with breastfeeding initiation and continuation, and to conduct a meta-analysis to produce summary relative risks (RRs) for selected factors. STUDY DESIGN: A systematic review using PubMed and CINAHL through March 2016 was conducted to identify relevant observational studies in developed nations, reporting a measure of risk for 1 or more of 6 quantitatively derived, high impact factors in relation to either breastfeeding initiation or continuation. One author abstracted data using a predesigned database, which was reviewed by a second independent author; data evaluation and interpretation included all co-authors. These factors were summarized using standard meta-analysis techniques. RESULTS: Six high impact factors were identified (smoking [39 papers], mode of delivery [47 papers], parity [31 papers], dyad separation [17 papers], maternal education [62 papers], and maternal breastfeeding education [32 papers]). Summary RR from random-effects models for breastfeeding initiation were highest for high vs low maternal education (RR 2.28 [95% CI 1.92-2.70]), dyad connection vs not (RR 2.01 [95% CI 1.38-2.92]), and maternal nonsmoking vs smoking (RR = 1.76 [95% CI 1.59-1.95]); results were similar for breastfeeding continuation. CONCLUSIONS: Despite methodological heterogeneity across studies, relatively consistent results were observed for these perinatally identifiable factors associated with breastfeeding initiation and continuation, which may be informative in developing targeted interventions to provide education and support for successful breastfeeding in more families.

The relationship between surrounding greenness in childhood and adolescence and depressive symptoms in adolescence and early adulthood.

PURPOSE: Exposure to nature, particularly vegetation (greenness), may be beneficial for mental health. We investigated whether higher surrounding greenness in early life was associated with subsequent reduced risk of depressive symptoms and whether this association was modified by age, sex, or population density. METHODS: Participants from the Growing Up Today Study were included if they reported on depressive symptoms between 1999 and 2013. Greenness exposure was characterized as the cumulative average normalized difference vegetation index value (1000 m resolution) from 1989 until 2 years before outcome assessment or age 18 based on geocoded addresses. We defined high depressive symptoms as the top 10% of scores on the McKnight Risk Factor Survey or the Center for Epidemiologic Studies of Depression scale, depending on the questionnaire. Data were analyzed using Cox proportional hazards model adjusted for socioeconomic status and other confounders. RESULTS: There was a 6% lower incidence of high depressive symptoms associated with an interquartile range increase in greenness (95% confidence interval, 11%-0%). This relationship was stronger in higher population density areas (>1000 people/mi2, 8% lower incidence, 95% confidence interval 15%-1%). CONCLUSIONS: Living in an area with greater surrounding greenness during childhood may be beneficial for mental health, particularly in more urban areas.

The Association Between Natural Environments and Depressive Symptoms in Adolescents Living in the United States.

PURPOSE: Exposure to nature and natural environments may be beneficial for mental health; however, most population-based studies have been conducted among adults whereas few have focused on adolescents. We aimed to investigate the relationship between both greenness (vegetation) and blue space (water), and depressive symptoms among teenagers in the United States. METHODS: The study population included 9,385 participants ages 12-18 in the 1999 wave of the Growing Up Today Study. We characterized greenness exposure using the Normalized Difference Vegetation Index at a 250-m and 1,250-m radius around a subject's residence using data from the moderate-resolution imaging spectroradiometer onboard the National Aeronautics and Space Administration's Terra satellite. Exposure to blue space was defined as the presence of blue space within a 250-m and 1,250-m radius and distance to the nearest blue space. We used logistic regression models to examine associations with high depressive symptoms, measured using self-reported responses to the McKnight Risk Factor Survey. RESULTS: An interquartile range higher peak greenness in the 1,250-m buffer was associated with 11% lower odds of high depressive symptoms (95% confidence interval .79-.99). Although not statistically significant, this association was stronger in middle school students than in high school students. No such association was seen for blue spaces. CONCLUSIONS: Surrounding greenness, but not blue space, was associated with lower odds of high depressive symptoms in this population of more than 9,000 U.S. adolescents. This association was stronger in middle school students than in high school students. Incorporating vegetation into residential areas may be beneficial for mental health.

Residential greenness: current perspectives on its impact on maternal health and pregnancy outcomes.

Recent research in environmental epidemiology has attempted to estimate the effects of exposure to nature, often operationalized as vegetation, on health. Although many analyses have focused on vegetation or greenness with regard to physical activity and weight status, an incipient area of interest concerns maternal health and birth outcomes. This paper reviews 14 studies that examined the association between greenness and maternal or infant health. Most studies were cross-sectional and conducted in birth cohorts. Several studies found evidence for positive associations between greenness and birth weight and maternal peripartum depression. Few studies found evidence for an association between greenness and gestational age or other birth outcomes, or between greenness and preeclampsia or gestational diabetes. Several assessed effect modification by individual or area-level socioeconomic status and found that effects were stronger among those of lower socioeconomic status. Few studies conducted mediation analyses of any kind. Future research should include more diverse birth outcomes and focus on maternal health (especially mental health) and capitalize on richer exposure information during pregnancy rather than cross-sectional assessment at birth.

Relationship between Recreational Resources in the School Neighborhood and Changes in Fitness in New York City Public School Students.

Physical fitness in children has many beneficial effects, including the maintenance of a healthy weight. The built environment may influence youths' physical fitness by encouraging physical activity. This paper assessed whether higher density of parks, playgrounds, and sports facilities around a school is related to improvements in fitness in middle school boys and girls. Fitness scores and other student covariates collected as part of NYC FITNESSGRAM between the 2006-2007 and 2010-2011 school years were linked with school neighborhood data on characteristics of the built environment for NYC public school students in grades 6-8. Data were analyzed in 2015. Medium, but not high, density of recreational resources in the area surrounding a school was associated with greater annual improvements in fitness for both boys and girls. This association appeared to be driven mainly by the presence of parks. Findings for sports facilities and playgrounds were inconsistent. Overall, few associations were observed between recreational resources near a school and changes in student fitness. Future studies of school influences on student fitness should consider the influence of school resources and the home neighborhood.

Retail Pharmacy Policy to End the Sale of Tobacco Products: What Is the Impact on Disparity in Neighborhood Density of Tobacco Outlets?

BACKGROUND: Population-level research on the implications of retail pharmacy policies to end the sale of tobacco products is scant, and the impact of such policies on racial/ethnic and socioeconomic disparities across neighborhoods in access to tobacco products remains unexplored. METHODS: We investigated the association between neighborhood sociodemographic characteristics and tobacco retail density in Rhode Island (RI; N = 240 census tracts). We also investigated whether the CVS Health (N = 60) policy to end the sale of tobacco products reduces the disparity in the density of tobacco retail across neighborhoods, and we conducted a prospective policy analysis to determine whether a similar policy change in all pharmacies in RI (N = 135) would reduce the disparity in tobacco retail density. RESULTS: The results revealed statistically significant associations between neighborhood sociodemographic characteristics and tobacco retail outlet density across RI neighborhoods. The results when excluding the CVS Health locations, as well as all pharmacies as tobacco retailers, revealed no change in the pattern for this association. CONCLUSIONS: The results of this study suggest that while a commendable tobacco control policy, the CVS Health policy appears to have no impact on the neighborhood racial/ethnic and socioeconomic disparities in the density of tobacco retailers in RI. Prospective policy analyses showed no impact on this disparity even if all other pharmacies in the state adopted a similar policy. IMPACT: Policy efforts aimed at reducing the disparity in access to tobacco products should focus on reducing the density of tobacco outlets in poor and racial/ethnic neighborhoods. Cancer Epidemiol Biomarkers Prev; 25(9); 1305-10. ©2016 AACR.

The effects of changes in physical fitness on academic performance among New York City youth.

PURPOSE: To evaluate whether a change in fitness is associated with academic outcomes in New York City (NYC) middle-school students using longitudinal data and to evaluate whether this relationship is modified by student household poverty. METHODS: This was a longitudinal study of 83,111 New York City middle-school students enrolled between 2006-2007 and 2011-2012. Fitness was measured as a composite percentile based on three fitness tests and categorized based on change from the previous year. The effect of the fitness change level on academic outcomes, measured as a composite percentile based on state standardized mathematics and English Language Arts test scores, was estimated using a multilevel growth model. Models were stratified by sex, and additional models were tested stratified by student household poverty. RESULTS: For both girls and boys, a substantial increase in fitness from the previous year resulted in a greater improvement in academic ranking than was seen in the reference group (girls: .36 greater percentile point improvement, 95% confidence interval: .09-.63; boys: .38 greater percentile point improvement, 95% confidence interval: .09-.66). A substantial decrease in fitness was associated with a decrease in academics in both boys and girls. Effects of fitness on academics were stronger in high-poverty boys and girls than in low-poverty boys and girls. CONCLUSIONS: Academic rankings improved for boys and girls who increased their fitness level by >20 percentile points compared to other students. Opportunities for increased physical fitness may be important to support academic performance.