'Nobody Shops at the Neighborhood Store': Leveraging a Community's Pediatric Fresh Produce Prescription Program to Inform Future Participating Store Redemption Locations.

Research examining the nature of food shopping often considers proximity to the nearest or overall distance travelled to multiple stores. Such studies make up a portion of new work on so-called 'food deserts' and the issues inherent in the term, including that most people do not shop at their nearest store, and mobility challenges vary vastly from one person to the next. Increasing the knowledge base on shopping characteristics could be useful for behavioral interventions and programs aimed at increasing healthy food shopping. In this study, we examined the shopping characteristics of 627 caregivers whose children were enrolled in a pediatric fresh produce prescription program at one of three large pediatric clinics in Flint, Michigan. We compared these characteristics to the potential of a new food cooperative to improve geographic accessibility to healthy food. In particular, we propose the expansion of the prescription program to this new cooperative for health-related as well as local economic development reasons. Our work bridges topics of interest to researchers and practitioners working in nutrition, food access, and economic development.

Historical Structural Racism in the Built Environment and Contemporary Children's Opportunities.

BACKGROUND AND OBJECTIVES: There are well-documented links between structural racism and inequities in children's opportunities. Yet, when it comes to understanding the role of the built environment, a disproportionate focus on redlining obscures other historical policies and practices such as blockbusting, freeway displacement, and urban renewal that may impact contemporary child development. We hypothesized that historical structural racism in Allegheny County, Pennsylvania's, built environment would be associated with fewer contemporary educational, socioeconomic, and health opportunities. We also hypothesized that these measures would explain more collective variance in children's opportunities than redlining alone. METHODS: We used geospatial data from the US Census, Mapping Inequality Project, and other archival sources to construct historical measures of redlining, blockbusting, freeway displacement, and urban renewal in ArcGIS at the census tract level. These were linked with data from the Child Opportunity Index 2.0 to measure children's opportunities across domains of education, socioeconomic status, and health. We ran spatial regression analyses in Stata 18.0 to examine individual and collective associations between structural racism and children's opportunities. RESULTS: Historical redlining, blockbusting, and urban renewal were largely associated with fewer contemporary educational, socioeconomic, and health opportunities, and explained up to 47.4% of the variance in children's opportunities. The measures collectively explained more variance in children's opportunities than redlining alone. CONCLUSIONS: In support of our hypotheses, novel measures of structural racism were related to present-day differences in children's opportunities. Findings lay the groundwork for future research focused on repairing longstanding harm perpetuated by structural racism.

Increased disparities in waitlist and post-heart transplantation outcomes according to socioeconomic status with the new heart transplant allocation system.

BACKGROUND: The study objective was to assess disparities in outcomes in the waitlist and post-heart transplantation (HT) according to socioeconomic status (SES) in the old and new U.S. HT allocation systems. METHODS: Adult HT candidates in the United Network for Organ Sharing database from 2014 through 2021 were included. Old or new system classification was according to listing before or after October 18, 2018. SES was stratified by patient ZIP code and median household income via U.S. Census Bureau and classified into terciles. Competing waitlist outcomes and post-transplantation survival were compared between systems. RESULTS: In total, 26,450 patients were included. Waitlisted candidates with low SES were more frequently younger, female, African American, and with higher body mass index. Reduced cumulative incidence (CI) of HT in the old system occurred in low SES (53.5%) compared to middle (55.7%, p = 0.046), and high (57.9%, p < 0.001). In the new system, the CI of HT was 65.3% in the low SES vs middle (67.6%, p = 0.002) and high (70.2%, p < 0.001), and SES remained significant in the adjusted analysis. In the old system, CI of death/delisting was similar across SES. In the new system, low SES had increased CI of death/delisting (7.4%) vs middle (6%, p = 0.012) and high (5.4%, p = 0.002). The old system showed similar 1-year survival across SES. In the new system, recipients with low SES had decreased 1-year survival (p = 0.041). CONCLUSIONS: SES affects waitlist and post-transplant outcomes. In the new system, all SES had increased access to HT; however, low SES had increased death/delisting due to worsening clinical status and decreased post-transplant survival.

Relative impacts of a virtual cooking and nutrition program for children and families.

Among the many factors contributing to increased consumption of ultraprocessed foods, a societal decline in cooking skills is a barrier to achieving healthy dietary patterns among children and adolescents. The current study assessed the effectiveness of a healthy cooking program, its geographic reach, and whether program format (child only, in-person format vs. family-based, virtual format) influenced outcomes. This was a quasi-experimental comparison study using youths' (8-18 years old) pre-post surveys, paired t-tests, propensity score matching, and hot spot analysis. Children participated in one of two healthy cooking programs: Flint Kids Cook (FKC)] in-person or [Flint Families Cook (FFC) virtual. FKC was facilitated inside a farmers' market commercial kitchen, whereas FFC took place virtually, in families' homes. Youth were eligible to participate in FKC if they were age 8-18 years, spoke English, and had not participated in a prior session. Families were eligible to participate in FFC if they had a child(ren) age 8-18 years, spoke English, and had not participated in a prior session of FKC or FFC. A total of 246 children (152 FKC; 94 FFC) completed assessments. FFC participants reported improved cooking self-efficacy (p < 0.001), intake of vegetables (p = 0.04), health-related quality of life (HRQoL; p = 0.01), and physical functioning (p < 0.001). Geographic reach, cooking self-efficacy, attitude towards cooking, and HRQoL exit scores did not differ between virtual or in-person programs. However, virtual program participants reported higher intake of whole grains (p = 0.02) and total fruits (p = 0.02) than in-person participants. Differences in outcomes based on program format included notable dietary improvements among youth who participated in the family-based virtual program.

Community identified characteristics related to illegal dumping; a mixed methods study to inform prevention.

Illegal dumping is a public health burden for communities suffering from historical disinvestment. We conducted a mixed methods study to answer: 1) What are stakeholder perspectives on social/environmental determinants of illegal dumping? and 2) Do these or other characteristics predict known locations of illegal dumping? We employed an exploratory sequential design in which we collected and analyzed in-depth interviews (n=12) with service providers and residents and subsequently collected and analyzed data from multiple secondary sources. Stakeholders endorsed nine determinants of illegal dumping: Economic Decline, Scale of Vacancy, Lack of Monitoring, Poor Visibility, Physical Disorder, Illegal Activity, Norms, Accessibility, and Seclusion. Results demonstrate important community-identified, modifiable, social, and environmental characteristics related to illegal dumping with the potential to inform effective prevention.

Built and social indices for hazards in Children's environments.

Leveraging the capabilities of the Historical Spatial Data Infrastructure (HSDI) and composite indices we explore the importance of children's built and social environments on health. We apply contemporary GIS methods to a set of 2000 historical school records contextualized within an existing HSDI to establish seven variables measuring the relative quality of each child's built and social environments. We then combined these variables to create a composite index that assesses acute (short-term) health risks generated by their environments. Our results show that higher acute index values significantly correlated with higher presence of disease in the home. Further, higher income significantly correlated with lower acute index values, indicating that the relative quality of children's environments in our study area were constrained by familial wealth. This work demonstrates the importance of analyzing multiple activity spaces when assessing built and social environments, as well as the importance of spatial microdata.

Establishing the Relative Accuracy of Using City Directories as Proxies to Define and Reconstruct Historical Alcohol Environments.

OBJECTIVE: Research on alcohol environments has established that poorer and minoritized communities are frequently overburdened by off-premise outlets (e.g., liquor stores). These outlets have more associated harms, including increased alcohol consumption and crime rates. Little, if any, research has shown how these socio-spatial disparities in exposure have grown or shifted over time, and no studies have established a method for re-creating historical alcohol environments. METHOD: Our results suggest that in our study city of Flint, MI, disparities in the alcohol environment have narrowed since 1950. Although liquor stores are still more likely to be located in poorer and more heavily African American neighborhoods, the pattern has become insignificant over time. Furthermore, the number of alcohol outlets per capita has declined. Thus, although the city remains more overburdened with alcohol outlets than its suburbs, the disparity has shrunk. CONCLUSIONS: This work has implications for those working in alcohol prevention and policy, as well as in urban planning. Practitioners and researchers can use this method to model alcohol availability over time in their own communities, which helps better inform the discussion on disparities experienced in poor and minoritized neighborhoods.

Neighborhood disadvantage, household chaos, and personal stressors: exploring early-life contextual factors and current mental health symptoms in college students.

OBJECTIVE: Using Bronfenbrenner's socio-ecological model as a frame, we explored the impact of neighborhood disadvantage, household chaos, and personal stressors on current mental health symptoms in college students. PARTICIPANTS: 144 students at a large, public university in the southern U.S. METHODS: Participants completed measures of demographics, family-of-origin household chaos, stressors, anxiety, and depression, and provided their childhood home ZIP code. Using U.S. Census Data, four structural indicators of neighborhood disadvantage were extracted and appended to each participant's ZIP code. RESULTS: Hierarchical regression revealed that all three variables predicted anxiety symptoms. However, only household chaos and personal stressors predicted current depressive symptoms. Unexpectedly, greater neighborhood disadvantage predicted lower levels of current anxiety. Mediation analyses demonstrated that personal stressors partially mediated the relationships between household chaos and mental health symptoms. CONCLUSIONS: College administration and counseling centers may wish to consider pre-college factors that influence college students' current anxious and depressive symptoms.

Linking Historical Discriminatory Housing Patterns to the Contemporary Alcohol Environment.

Research on alcohol outlet density consistently shows greater disparities in exposure in disinvested communities. Likewise, structural racism via discriminatory housing practices has created many of the issues that beset contemporary disinvested neighborhoods. Little work, however, has examined the relationship between housing practices and alcohol outlet disparities. The central premise of our work is that these discriminatory and inequitable practices create distinctions in the alcohol environment, and that such disparities have implications for work on alcohol policy. Here we link alcohol outlet density with a spatial database examining redlining, blockbusting, and gentrification in Baltimore, Maryland, and Flint, Michigan (two cities with common experiences of urban disinvestment over the last 50 years). Standard measures are used to account for the impacts of neighborhood racial, socioeconomic, and housing composition in a multilevel model. Our findings highlight that gentrification and redlining are strongly associated with alcohol outlet density, while blockbusting is not. Gentrification and redlining also frequently co-occur in inner-urban areas, while the more suburban phenomenon of blockbusting rarely overlaps with either. These findings further contextualize nascent work on structural racism in housing that illustrates important disparities along the lines of these distinct practices. Future work should consider how legacy impacts of discriminatory housing patterns impact our communities today.

Using trajectory modeling of spatio-temporal trends to illustrate disparities in COVID-19 death in flint and Genesee County, Michigan.

COVID-19's rapid onset left many public health entities scrambling. But establishing community-academic partnerships to digest data and create advocacy steps offers an opportunity to link research to action. Here we document disparities in COVID-19 death uncovered during a collaboration between a health department and university research center. We geocoded COVID-19 deaths in Genesee County, Michigan, to model clusters during two waves in spring and fall 2020. We then aggregated these deaths to census block groups, where group-based trajectory modeling identified latent patterns of change and continuity. Linking with socioeconomic data, we identified the most affected communities. We discovered a geographic and racial gap in COVID-19 deaths during the first wave, largely eliminated during the second. Our partnership generated added and immediate value for community partners, including around prevention, testing, treatment, and vaccination. Our identification of the aforementioned racial disparity helped our community nearly eliminate disparities during the second wave.

Hypoxia signatures in closed-circuit rebreather divers.

INTRODUCTION: Faults or errors during use of closed-circuit rebreathers (CCRs) can cause hypoxia. Military aviators face a similar risk of hypoxia and undergo awareness training to determine their 'hypoxia signature', a personalised, reproducible set of symptoms. We aimed to establish a hypoxia signature among divers, and to investigate their ability to detect hypoxia and self-rescue while cognitively overloaded. METHODS: Eight CCR divers and 12 scuba divers underwent an initial unblinded hypoxia exposure followed by three trials; a second hypoxic trial and two normoxic trials in randomised order. Hypoxia was induced by breathing on a CCR with no oxygen supply. Subjects pedalled on a cycle ergometer while playing a neurocognitive computer game to simulate real world task loading. Subjects identified hypoxia symptoms by pointing to a board listing common hypoxia symptoms, and were instructed to perform a 'bailout' procedure to mimic self-rescue if they perceived hypoxia. Divers were prompted to bailout if peripheral oxygen saturation fell to 75%, or after six minutes during normoxic trials. Subsequently we interviewed subjects to determine their ability to distinguish hypoxia from normoxia. RESULTS: Ninety-five percent of subjects (19/20) showed agreement between unblinded and blinded hypoxia symptoms. Subjects correctly identified the gas mixture in 85% of the trials. During unblinded hypoxia, only 25% (5/20) of subjects performed unprompted bailout. Fifty-five percent of subjects (11/20) correctly performed the bailout but only when prompted, while 15% (3/20) were unable to bailout despite prompting. During blinded hypoxia 45% of subjects (9/20) performed the bailout unprompted while 15% (3/20) remained unable to bailout despite prompting. CONCLUSIONS: Although our data support a normobaric hypoxia signature among both CCR and scuba divers under experimental conditions, most subjects were unable to recognise hypoxia in real time and perform a self-rescue unprompted, although this improved in the second hypoxia trial. These results do not support hypoxia exposure training for CCR divers.

Mapping the Way to Good Health: The Interdisciplinary Challenges of Geographers in Medical Research.

Geography has an important role to play in shaping the direction of medical research. In particular, its tools and theory provide essential understanding to the impacts of place on health behaviors and outcomes. Understanding some of its evolution-particularly into the subfield of medical geography-is therefore useful both for geographers and medical researchers. In this paper, we present some of the debates that geographers have grappled with, the growth of GIS (particularly in the context of medical research), some important methodological considerations that geographers help center, and some recommendations for future work at this nexus. Throughout, we speak from the perspective of geographers who have worked nearly exclusively in the health sciences since obtaining our PhDs.

Not built for families: Associations between neighborhood disinvestment and reduced parental cognitive stimulation.

Infants learn and develop within an ecological context that includes family, peers, and broader built and social environments. This development relies on proximal processes-reciprocal interactions between infants and the people and environments around them that help them understand their world. Most research examining predictors of proximal processes like parent-child interaction and parenting has focused on elements within the home and family. However, factors like the neighborhood built environment may also exhibit an influence, and may be particularly critical in infancy, as socioeconomic disparities in cognition and language emerge early in life. Moreover, influence from the built environment could independently exacerbate these disparities, as research indicates that neighborhood impacts may be especially relevant for families living in neighborhoods that have experienced disinvestment and therefore have been under-resourced. The current study examines these questions by determining the association of neighborhood vacancy rate and observed physical disorder-indicators of poverty, residential stability, and long-term structural discrimination-with parental cognitive stimulation among predominantly Black/African-American families in Flint, Michigan. Flint is particularly salient for this study because vacancy rates and disinvestment vary widely across the city, driven by its long-time status as a city struggling economically. Regression analyses controlling for caregiver education, mental health, and social support indicated that vacancy rate and physical disorder negatively predicted parental cognitive stimulation. Moreover, there were significant interactions between the built environment and social support, indicating that, particularly for parent-child shared reading, vacancy rate and physical disorder predicted reduced shared reading only when parents had limited social support. These results have important implications for public policy around vacant property demolition and neighborhood reinvestment programs, as they indicate that the neighborhood built environment is associated with parenting behaviors that have important impacts on infants' learning and development.

Validating a geospatial healthfulness index with self-reported chronic disease and health outcomes.

Leveraging community engagement from past research may yield frameworks on which to build new inquiries. We previously integrated community voice into the development of a healthfulness index to increase awareness of social determinants of health in the built environment and inform deployment of public health interventions in the Flint (Michigan, USA) Center for Health Equity Solutions. Here we combine the healthfulness index with self-reported chronic disease and health outcomes (n = 12,279) from a community-based healthcare entity, the Genesee Health Plan. The healthfulness index purports to predict how health-promoting a neighborhood is based on many spatially varying characteristics; by linking our health plan data to this index, we validate the effectiveness of the healthfulness index. After geocoding all enrollees and joining their healthfulness scores, we conducted a series of logistic regressions to compare the relationship between self-reported outcomes and healthfulness. Matching the two intervention projects of our center (revolving around healthy eating & physical activity in project 1 and mental health sustainment & substance use prevention in project 2), our analyses also focused on classes of outcomes related to a) cardiovascular disease and b) mental health. In only select cases, higher (better) healthfulness scores from each project were independently associated with better cardiovascular and mental health outcomes, controlling for age, race, and sex. Generally, however, healthfulness did not add predictive strength to the association between health and sociodemographic covariates. Even so, the use of composite healthfulness indices to describe the health-promoting or degrading qualities of a neighborhood could be valuable in identifying differences in health outcomes. Future researchers could further explore healthcare claims datasets to increase understanding of the links between healthfulness and health outcomes. This and future work will be valuable in advocacy toward additional healthfulness indices to aid other communities in enriching understanding between the built environment and health.

Inequitable Housing Practices and Youth Internalizing Symptoms: Mediation Via Perceptions of Neighborhood Cohesion.

Disordered urban environments negatively impact mental health symptoms and disorders. While many aspects of the built environment have been studied, one influence may come from inequitable, discriminatory housing practices such as redlining, blockbusting, and gentrification. The patterns of disinvestment and reinvestment that follow may be an underlying mechanism predicting poor mental health. In this study, we examine pathways between such practices and internalizing symptoms (i.e., anxiety and depression) among a sample of African American youth in Baltimore, Maryland, considering moderation and mediation pathways including neighborhood social cohesion and sex. In our direct models, the inequitable housing practices were not significant predictors of social cohesion. In our sex moderation model, however, we find negative influences on social cohesion: for girls from gentrification, and for boys from blockbusting. Our moderated mediation model shows that girls in gentrifying neighborhoods who experience lower social cohesion have higher levels of internalizing symptoms. Likewise for boys, living in a formerly blockbusted neighborhood generates poorer social cohesion, which in turn drives higher rates of internalizing symptoms. A key implication of this work is that, in addition to standard measures of the contemporary built environment, considering other invisible patterns related to discriminatory and inequitable housing practices is important in understanding the types of neighborhoods where anxiety and depression are more prevalent. And while some recent work has discussed the importance of considering phenomena like redlining in considering long-term trajectories of neighborhoods, other patterns such as blockbusting and gentrification may be equally important.

Identifying barriers to emergency department-initiated buprenorphine: A spatial analysis of treatment facility access in Michigan.

STUDY OBJECTIVES: Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access. METHODS: Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers. RESULTS: Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress. CONCLUSION: Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.

Trajectory Modeling of Spatio-Temporal Trends in COVID-19 Incidence in Flint and Genesee County, Michigan.

PURPOSE: The establishment of community-academic partnerships to digest data and create actionable policy and advocacy steps is of continuing importance. In this paper, we document COVID-19 racial and geographic disparities uncovered via a collaboration between a local health department and university research center. METHODS: We leverage individual level data for all COVID-19 cases aggregated to the census block group level, where group-based trajectory modeling was employed to identify latent patterns of change and continuity in COVID-19 diagnoses. RESULTS: Linking with socioeconomic data from the census, we identified the types of communities most heavily affected by each of Michigan's two waves (in spring and fall of 2020). This includes a geographic and racial gap in COVID-19 cases during the first wave, which is largely eliminated during the second wave. CONCLUSIONS: Our work has been extremely valuable for community partners, informing community-level response toward testing, treatment, and vaccination. In particular, identifying and conducting advocacy on the sizeable racial disparity in COVID-19 cases during the first wave in spring 2020 helped our community nearly eliminate disparities throughout the second wave in fall 2020.

Right Sizing Flint's Infrastructure in the Wake of the Flint Water Crisis Would Constitute an Additional Environmental Injustice.

Right sizing has become an essential talking point in discussing next steps for postindustrial and shrinking cities as they struggle to maintain outdated, outsized infrastructure. Yet the literature has been clear that balancing economic and social objectives must be a key part of the discussion, especially given that historical patterns of disinvestment have disproportionately affected socioeconomically disadvantaged and racial/ethnic minority populations. In this Viewpoint, we illuminate concerns on a recent article published in this journal on right sizing that Flint (MI) should have enacted in the wake of its catastrophic water crisis. We present the nature of decline in Flint, as well as evidence from Flint's recent master plan and its history with urban renewal that demonstrates why recommending such a policy not only goes against common urban planning practice but misses the local context in Flint, which is marked by deep-seated apprehension of the inequitable underpinnings of historical urban planning practice.

Linking the Flint Food Store Survey: Is Objective or Perceived Access to Healthy Foods Associated with Glycemic Control in Patients with Type 2 Diabetes?

Type 2 diabetes mellitus (DM-2) remains a significant public health concern, particularly in low-income neighborhoods where healthy foods may be scarcer. Despite the well-known relationship between diet and diabetes, little evidence exists on the connections among the objectively measured community and consumer food environment, perception of food access, and diabetes management or outcomes. This cross-sectional, ecological study represents the first example of combining a GIS-based, objectively measured food store audit considering quality, variety, and price of foods in stores with a clinical survey of patients with DM-2 (n = 126). In this way, we offer evidence on the relationship between healthy food access-measured more robustly than proximity to or density of certain store types-and diabetes management knowledge, medication adherence, and glycemic control. Better glycemic control was not correlated with better overall food store score, meaning that people in neighborhoods with better access to healthy foods are not necessarily more likely to manage their diabetes. While perceived healthy food access was not correlated with glycemic control, it was strongly correlated with objective healthy food access at shorter distances from home. These results have great importance both for clinical understanding of the persistence of poor diabetes management outcomes and for the understanding of the influence of the food environment on health behaviors.