The Legacy of Redlining: Increasing Childhood Asthma Disparities Through Neighborhood Poverty.

RATIONALE: Identifying the root causes of racial disparities in childhood asthma is critical for health equity. OBJECTIVES: To determine if the 1930's racist policy of redlining led to present-day disparities in childhood asthma by increasing community-level poverty and decreasing neighborhood socioeconomic position (SEP). METHODS: We categorized census tracts at birth of participants from the Children's Respiratory and Environmental Workgroup birth cohort consortium into A, B, C, or D categories as defined by the Home Owners Loan Corporation (HOLC), with D being the highest perceived risk. Surrogates of present-day neighborhood-level SEP were determined for each tract including the percentage of low-income households, the CDC's social vulnerability index (SVI), and other tract-level variables. We performed causal mediation analysis, which, under the assumption of no unmeasured confounding, estimates the direct and mediated pathways by which redlining may cause asthma disparities through census tract-level mediators adjusting for individual-level covariates. MEASUREMENTS AND MAIN RESULTS: Of 4,849 children, the cumulative incidence of asthma through age 11 was 26.6% and 13.2% resided in census tracts with a HOLC grade of D. In mediation analyses, residing in grade D tracts (aOR = 1.03 [95%CI 1.01,1.05]) was significantly associated with childhood asthma, with 79% of this increased risk mediated by percentage of low-income households; results were similar for SVI and other tract-level variables. CONCLUSIONS: The historical structural racist policy of redlining led to present-day asthma disparities in part through decreased neighborhood SEP. Policies aimed at reversing the effects of structural racism should be considered to create more just, equitable, and healthy communities.

Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes.

BACKGROUND: Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS: This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS: 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS: We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data.

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

High Resolution and Spatiotemporal Place-Based Computable Exposures at Scale.

Place-based exposures, termed "geomarkers", are powerful determinants of health but are often understudied because of a lack of open data and integration tools. Existing DeGAUSS (Decentralized Geomarker Assessment for Multisite Studies) software has been successfully implemented in multi-site studies, ensuring reproducibility and protection of health information. However, DeGAUSS relies on transporting geomarker data, which is not feasible for high-resolution spatiotemporal data too large to store locally or download over the internet. We expanded the DeGAUSS framework for high-resolution spatiotemporal geomarkers. Our approach stores data subsets based on coarsened location and year in an online repository, and appropriate subsets are downloaded to complete exposure assessment locally using exact date and location. We created and validated two free and open-source DeGAUSS containers for estimation of high-resolution, daily ambient air pollutant exposures, transforming published exposure assessment models into computable exposures for geomarker assessment at scale.

Measuring adequacy of the midwifery workforce using standards of competency and scope of work: Exploring the density and distribution of midwives in three low- and middle-income countries using cross-sectional and geospatial data.

BACKGROUND: A global midwifery shortage hampers the goal of ending preventable maternal/newborn mortality and stillbirths. Whether current measures of midwifery workforce adequacy are valid is unknown. We compare two measures of density and distribution of midwifery professionals to assess their consistency, and explore how incorporating midwifery scope, competency, and the adjusting reference population impacts this critical metric. METHODS AND FINDINGS: We collected a census of midwives employed in eligible facilities in our study settings, (422 in Ghana; 909 in India), assessed the number practicing within the scope of work for midwifery professionals defined in the International Labor Organization International Standard Classification of Occupations, and whether they reported possessing the ICM essential competencies for basic midwifery practice. We altered the numerator, iteratively narrowing it from a simple count to include data on scope of practice and competency and reported changes in value. We altered the denominator by calculating the number of midwives per 10,000 total population, women of reproductive age, pregnancies, and births and explored variation in the indicator. Across four districts in Ghana, density of midwives decreased from 8.59/10,000 total population when counting midwives from facility staffing rosters to 1.30/10,000 total population when including only fully competent midwives by the ICM standard. In India, no midwives met the standard, thus the midwifery density of 1.37/10,000 total population from staffing rosters reduced to 0.00 considering competency. Changing the denominator to births vastly altered subnational measures, ranging from ~1700% change in Tolon to ~8700% in Thiruvallur. CONCLUSION: Our study shows that varying underlying parameters significantly affects the value of the estimate. Factoring in competency greatly impacts the effective coverage of midwifery professionals. Disproportionate differences were noted when need was estimated based on total population versus births. Future research should compare various estimates of midwifery density to health system process and outcome measures.

Regional Differences in Added Sweetener Knowledge, Consumption and Body Mass Index in People with HIV in the United States.

This analysis of U.S.-based survey data reports regional differences (Northeast, Midwest, South, and West) in sweetener knowledge, consumption, and body mass index (BMI) among 877 people with HIV (PLWH; median age 54 years). BMI was lowest in the West and highest in the Midwest. Respondents in the West reported greater sweetener knowledge than in the Northeast, Midwest, and South. Respondents from the West reported lower sweetener consumption than the Midwest and South. Regional differences in BMI, sweetener knowledge, and consumption were demonstrated. Findings support consideration of regional differences when providing nutrition education.

RESUMEN: Ese analisis de los datos de la encuesta con sede en los Estados Unidos informa las diferencias regionales (noreset, medio oeste, sur, y oeste) en el conocimiento de los edulcorantes, el consumo, y el índice de masa coporal (IMC) entre 877 personas con VIH (PVVS; mediana de edad de 54 anos). El IMC fue más bajo en el oeste y más alto en el medio oeste. Los encuestados en el oeste informaron un mayor conocimiento de edulcorantes que el noreste, el medio oeste, y el sur. Los encuestados del oeste informaron un menor consumo de edulcorantes que el medio oeste y el sur. Se demostraron diferencias regionales en el IMC, el conocimiento de edulcorantes, y el consumo. Los hallazgos apoyan la consideración de las diferencias regionales al proporcionar educación nutritional.

A distributed geospatial approach to describe community characteristics for multisite studies.

Understanding place-based contributors to health requires geographically and culturally diverse study populations, but sharing location data is a significant challenge to multisite studies. Here, we describe a standardized and reproducible method to perform geospatial analyses for multisite studies. Using census tract-level information, we created software for geocoding and geospatial data linkage that was distributed to a consortium of birth cohorts located throughout the USA. Individual sites performed geospatial linkages and returned tract-level information for 8810 children to a central site for analyses. Our generalizable approach demonstrates the feasibility of geospatial analyses across study sites to promote collaborative translational research.

The State of School Infrastructure in the Assembly Constituencies of Rural India: Analysis of 11 Census Indicators from Pre-Primary to Higher Education.

In India, assembly constituencies (ACs), represented by elected officials, are the primary geopolitical units for state-level policy development. However, data on social indicators are traditionally reported and analyzed at the district level, and are rarely available for ACs. Here, we combine village-level data from the 2011 Indian Census and AC shapefiles to systematically derive AC-level estimates for the first time. We apply this methodology to describe the distribution of 11 education infrastructures-ranging from pre-primary school to senior secondary school-across rural villages in 3773 ACs. We found high variability in access to higher education infrastructures and low variability in access to lower education variables. For 40.3% (25th percentile) to 79.7% (75th percentile) of villages in an AC, the nearest government senior secondary school was >5 km away, whereas the nearest government primary school was >5 km away in just 0% (25th percentile) to 1.9% (75th percentile) of villages in an AC. The states of Manipur, Arunachal Pradesh, and Bihar showed the greatest within-state variation in access to education infrastructures. We present a novel analysis of access to education infrastructure to inform AC-level policy, and demonstrate how geospatial and Census data can be leveraged to derive AC-level estimates for any population health and development indicators collected in the Census at the village level.

In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible?

Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.

A Community Resource Map to Support Clinical-Community Linkages in a Randomized Controlled Trial of Childhood Obesity, Eastern Massachusetts, 2014-2016.

BACKGROUND: Novel approaches to health care delivery that leverage community resources could improve outcomes for children at high risk for obesity. COMMUNITY CONTEXT: We describe the process by which we created an online interactive community resources map for use in the Connect for Health randomized controlled trial. The trial was conducted in the 6 pediatric practices that cared for the highest percentage of children with overweight or obesity within a large multi-specialty group practice in eastern Massachusetts. METHODS: By using semistructured interviews with parents and community partners and geographic information systems (GIS), we created and validated a community resource map for use in a randomized controlled trial for childhood obesity. We conducted semistructured interviews with 11 parents and received stakeholder feedback from 5 community partners, 2 pediatricians, and 3 obesity-built environment experts to identify community resources that could support behavior change. We used GIS databases to identify the location of resources. After the resources were validated, we created an online, interactive searchable map. We evaluated parent resource empowerment at baseline and follow-up, examined if the participant families went to new locations for physical activity and food shopping, and evaluated how satisfied the families were with the information they received. OUTCOME: Parents, community partners, and experts identified several resources to be included in the map, including farmers markets, supermarkets, parks, and fitness centers. Parents expressed the need for affordable activities. Parent resource empowerment increased by 0.25 units (95% confidence interval, 0.21-0.30) over the 1-year intervention period; 76.2% of participants were physically active at new places, 57.1% of participant families shopped at new locations; and 71.8% reported they were very satisfied with the information they received. INTERPRETATION: Parents and community partners identified several community resources that could help support behavior change. Parent resource empowerment and use of community resources increased over the intervention period, suggesting that community resource mapping should inform future interventions.

Adolescents' use of the built environment for physical activity.

BACKGROUND: Physical activity is a health-enhancing behavior, but few adolescents achieve the recommended levels of moderate-to-vigorous physical activity. Understanding how adolescents use different built environment spaces for physical activity and activity varies by location could help in designing effective interventions to promote moderate-to-vigorous physical activity. The objective of this study was to describe the locations where adolescents engage in physical activity and compare traditional intensity-based measures with continuous activity when describing built environment use patterns among adolescents. METHODS: Eighty adolescents aged 11-14 years recruited from community health and recreation centers. Adolescents wore accelerometers (Actigraph GT3X) and global positioning system receivers (QStarz BT-Q1000XT) for two separate weeks to record their physical activity levels and locations. Accelerometer data provided a continuous measure of physical activity and intensity-based measures (sedentary time, moderate-to-vigorous physical activity). Physical activity was mapped by land-use classification (home, school, park, playground, streets & sidewalks, other) using geographic information systems and this location-based activity was assessed for both continuous and intensity-based physical activity derived from mixed-effects models which accounted for repeated measures and clustering effects within person, date, school, and town. RESULTS: Mean daily moderate-to-vigorous physical activity was 22 minutes, mean sedentary time was 134 minutes. Moderate-to-vigorous physical activity occurred in bouts lasting up to 15 minutes. Compared to being at home, being at school, on the streets and sidewalks, in parks, and playgrounds were all associated with greater odds of being in moderate-to-vigorous physical activity and achieving higher overall activity levels. Playground use was associated with the highest physical activity level (ß = 172 activity counts per minute, SE = 4, p < 0.0001) and greatest odds of being in moderate-to-vigorous physical activity (odds ratio 8.3, 95% confidence interval 4.8-14.2). CONCLUSION: Adolescents were more likely to engage in physical activity, and achieved their highest physical activity levels, when using built environments located outdoors. Novel objective methods for determining physical activity can provide insight into adolescents' spatial physical activity patterns, which could help guide physical activity interventions. Promoting zoning and health policies that encourage the design and regular use of outdoor spaces may offer another promising opportunity for increasing adolescent physical activity.

The influence of the built environment on outcomes from a "walking school bus study": a cross-sectional analysis using geographical information systems.

Active commuting to school increases children's daily physical activity. The built environment is associated with children's physical activity levels in cross-sectional studies. This study examined the role of the built environment on the outcomes of a "walking school bus" study. Geographical information systems was used to map out and compare the built environments around schools participating in a pilot walking school bus randomised controlled trial, as well as along school routes. Multi-level modelling was used to determine the built environment attributes associated with the outcomes of active commuting to school and accelerometer-determined moderate-to-vigorous physical activity (MPVA). There were no differences in the surrounding built environments of control (n = 4) and intervention (n = 4) schools participating in the walking school bus study. Among school walking routes, park space was inversely associated with active commuting to school (ß = -0.008, SE = 0.004, P = 0.03), while mixed-land use was positively associated with daily MPVA (ß = 60.0, SE = 24.3, P = 0.02). There was effect modification such that high traffic volume and high street connectivity were associated with greater moderate-to-vigorous physical activity. The results of this study suggest that the built environment may play a role in active school commuting outcomes and daily physical activity.

Distance to hospital and utilization of surgical services in Haiti: do children, delivering mothers, and patients with emergent surgical conditions experience greater geographical barriers to surgical care?

BACKGROUND: An inverse relationship between healthcare utilization and distance to care has been previously described. The purpose of this study was to evaluate this effect related to emergency and essential surgical care in central Haiti. METHODS: We conducted a retrospective review of operative logbooks from the Clinique Bon Sauveur in Cange, Haiti, from 2008 to 2010. We used Geographic Information Systems to map the home locations of all patients. Spearman's correlation was used to determine the relationship between surgical utilization and distance, and a multivariate linear regression model identified characteristics associated with differences in distances traveled to care. RESULTS: The highest annual surgical utilization rate was 184 operations/100,000 inhabitants. We found a significant inverse correlation between surgical utilization rate and distance from residence to hospital (rs = -0.68, p = 0.02). The median distance from residence to hospital was 55.9 km. Pediatric patients lived 10.1% closer to the hospital than adults (p < 0.01), and distance from residence to hospital was not significantly different between men and women (p = 0.25). Patients who received obstetric or gynecologic surgery originated 7.8% closer to the hospital than patients seeking other operations (p < 0.01), and patients who received emergent surgical care originated 24.8% closer to the hospital than patients who received elective surgery (p < 0.01). CONCLUSIONS: Utilization of surgical services was low and inversely related to distance from residence to hospital in rural areas of central Haiti. Children and patients receiving obstetric, gynecologic or emergent surgery lived significantly closer to the hospital, and these groups may need special attention to ensure adequate access to surgical care.

Combining global positioning system and accelerometer data to determine the locations of physical activity in children.

National trends indicate that children and adolescents are not achieving sufficient levels of physical activity. Combining global positioning system (GPS) technology with accelerometers has the potential to provide an objective determination in locations where youth engage in physical activity. The aim of this study was to identify the optimal methods for collecting combined accelerometer and GPS data in youth, to best locate where children spend time and are physically active. A convenience sample of 24 mid-school children in Massachusetts was included. Accelerometers and GPS units were used to quantify and locate childhood physical activity over 5 weekdays and 2 weekend days. Accelerometer and GPS data were joined by time and mapped with a geographical information system (GIS) using ArcGIS software. Data were collected in winter, spring, summer in 2009-2010, collecting a total of 26,406 matched datapoints overall. Matched data yield was low (19.1% total), regardless of season (winter, 12.8%; spring, 30.1%; summer, 14.3%). Teacher-provided, pre-charged equipment yielded the most matched (30.1%; range: 10.1-52.3%) and greatest average days (6.1 days) of data. Across all seasons, children spent most of their time at home. Outdoor use patterns appeared to vary by season, with street use increasing in spring, and park and playground use increasing in summer. Children spent equal amounts of physical activity time at home and walking in the streets. Overall, the various methods for combining GPS and accelerometer data provided similarly low amounts of combined data. No combined GPS and accelerometer data collection method proved superior in every data return category, but use of GIS to map joined accelerometer and GPS data can demarcate childhood physical activity locations.

The impact of geographic proximity to transplant center on outcomes after allogeneic hematopoietic stem cell transplantation.

Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) need access to specialized care. We hypothesized that access to the transplant center after HSCT may be challenging for patients living in geographically distant areas, and that this would have an adverse effect on their outcome. We analyzed 1912 adult patients who underwent allogeneic HSCT at the Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) between 1996 and 2009 and who resided within 6 hours driving time of the institution. Driving time from primary residence to DF/BWCC based on zipcode was determined using geographic information systems. The median driving time (range) to DF/BWCC was 72 (2-358) minutes. When patients were stratified by driving time quartile, overall survival (OS) after HSCT was similar in the first year but worse after 1 year in patients in the top quartile (≥ 160 minutes driving time). In a landmark analysis of the 909 patients alive and free of disease at 1 year, 5-year OS was 76% and 65% for patients in the first (≤ 40 minutes) and fourth (≥ 160 minutes) quartiles, respectively (P = .027). This was confirmed in a multivariable analysis. The difference appeared to be mostly because of an increase in nonrelapse mortality. The number of visits to the transplant center between day 100 and 365 after HSCT declined significantly with increasing driving time to the transplant center, which was independently associated with worse survival. Long driving time to the transplant center is associated with worse OS in patients alive and disease-free 1 year after HSCT, independently of other patient-, disease-, and HSCT-related variables. This may be in part related to the lower frequency of post-HSCT visits in patients living farther away.