Clustering of unhealthy behaviors in a nationally representative sample of U.S. children and adolescents.

Poor diet, low physical activity, sedentary behavior and smoking are modifiable risk factors for chronic diseases that often develop early in life. An improved understanding of how unhealthy behaviors co-occur within individual children across childhood and adolescence could inform the development of more effective prevention approaches. Using data from the 2011-2016 National Health and Nutrition Examination Survey, we calculated weighted prevalence of five unhealthy behaviors - excessive screen time, poor diet quality, low physical activity, fast food consumption, and smoking (adolescents only) - alone and in combination among U.S. children and adolescents, stratified by age group (2-5, 6-11, 12-15, and 16-19 years). Multivariable logistic regression was used to estimate associations between health behavior clustering (≥2 unhealthy behaviors) and sociodemographic characteristics by age group. Among 7714 children and adolescents, the most prevalent behaviors were excessive screen time and poor diet quality. Unhealthy behavior clustering increased significantly with age (from 29.0% for ages 2-5 to 73.9% for ages 16-19 years, p-trend: <0.0001). The most common health behavior combination was excessive screen time and poor diet (from 14.4% prevalence for ages 2-5 to 45.3% for ages 16-19 years). Smoking prevalence was low, but 97% of smokers had ≥1 other unhealthy behavior. Unhealthy behavior clustering was significantly more prevalent among black than white children (ages 2-5 and 6-11) and less prevalent among Hispanic older adolescents (age 16-19). Associations with household characteristics varied by age group. These results provide a population-level understanding of the extent to which unhealthy behaviors co-occur in U.S. children and adolescents.

Longitudinal Associations of Smoke-Free Policies and Incident Cardiovascular Disease: CARDIA Study.

BACKGROUND: Smoke-free legislation has been associated with lower rates of cardiovascular disease hospital admissions in ecological studies. However, prior studies lacked detailed information on individual-level factors (eg, sociodemographic and clinical characteristics) that could potentially confound associations. Our objective was to estimate associations of smoke-free policies with incident cardiovascular disease in a longitudinal cohort after controlling for sociodemographics, cardiovascular disease risk factors, and policy covariates. METHODS: Longitudinal data from 3783 black and white adults in the CARDIA study (Coronary Artery Risk Development in Young Adults; 1995-2015) were linked to state, county, and local 100% smoke-free policies in bars, restaurants, and nonhospitality workplaces by Census tract. Extended Cox regression estimated hazard ratios (HRs) of incident cardiovascular disease associated with time-dependent smoke-free policy exposures. Models were adjusted for sociodemographic characteristics, cardiovascular disease risk factors, state cigarette tax, participant-reported presence of a smoking ban at their workplace, field center, and metropolitan statistical area poverty. RESULTS: During a median follow-up of 20 years (68 332 total person-years), 172 participants had an incident cardiovascular disease event (2.5 per 1000 person-years). Over the follow-up period, 80% of participants lived in areas with smoke-free policies in restaurants, 67% in bars, and 65% in nonhospitality workplaces. In fully adjusted models, participants living in an area with a restaurant, bar, or workplace smoke-free policy had a lower risk of incident cardiovascular disease compared with those in areas without smoke-free policies (HR, 0.75, 95% confidence interval, 0.49-1.15; HR, 0.76, 95% confidence interval, 0.47-1.24; HR, 0.54, 95% confidence interval, 0.34-0.86, respectively; HR, 0.58, 95% confidence interval, 0.33-1.00 for living in an area with all 3 types of policies compared with none). The estimated preventive fraction was 25% for restaurant policies, 24% for bar policies, and 46% for workplace policies. CONCLUSIONS: Consistent with prior ecological studies, these individual-based data add to the evidence that 100% smoke-free policies are associated with lower risk of cardiovascular disease among middle-aged adults.

Neighborhood Physical Disorder and Adverse Pregnancy Outcomes among Women in Chicago: a Cross-Sectional Analysis of Electronic Health Record Data.

Adverse pregnancy outcomes increase infants' risk for mortality and future health problems. Neighborhood physical disorder may contribute to adverse pregnancy outcomes by increasing maternal chronic stress. Google Street View technology presents a novel method for assessing neighborhood physical disorder but has not been previously examined in the context of birth outcomes. In this cross-sectional study, trained raters used Google's Street View imagery to virtually audit a randomly sampled block within each Chicago census tract (n = 809) for nine indicators of physical disorder. We used an item-response theory model and spatial interpolation to calculate tract-level neighborhood physical disorder scores across Chicago. We linked these data with geocoded electronic health record data from a large, academic women's hospital in Chicago (2015-2017, n = 14,309 births). We used three-level hierarchical Poisson regression to estimate prevalence ratios for the associations of neighborhood physical disorder with preterm birth (overall and spontaneous), small for gestational age (SGA), and hypertensive disorder of pregnancy (HDP). After adjustment for maternal sociodemographics, multiparity, and season of birth, living in a neighborhood with high physical disorder was associated with higher prevalence of PTB, SGA, and HDP (prevalence ratios and 95% confidence intervals 1.21 (1.06, 1.39) for PTB, 1.13 (1.01, 1.37) for SGA, and 1.23 (1.07, 1.42) for HDP). Adjustment for neighborhood poverty and maternal health conditions (e.g., hypertension, diabetes, asthma, substance use) attenuated associations. Results suggest that an adverse neighborhood physical environment may contribute to adverse pregnancy outcomes. However, future work is needed to disentangle the unique contribution of physical disorder from other characteristics of disadvantaged neighborhoods.

Longitudinal Associations of Cigarette Prices With Smoking Cessation: The Coronary Artery Risk Development in Young Adults Study.

INTRODUCTION: Few studies have used longitudinal cohort data to examine associations of cigarette prices with smoking cessation or whether price sensitivity varies by income or education. This study examines these associations in a multicenter US cohort and explores whether associations vary by education and income. METHODS: Longitudinal data from baseline daily cigarette smokers aged 18-30 years in the Coronary Artery Risk Development in Young Adults study were linked to inflation-adjusted cigarette carton prices from the Council for Community and Economic Research Cost of Living Index based on residential address at baseline and in years 7, 10, and 15 (1985-2001). Multivariable Cox models estimated hazard ratios (HRs) of first (any) smoking cessation and sustained smoking cessation (no relapse) associated with each $1 increase in time-dependent cigarette price over 15 years of follow-up. Models were adjusted for sociodemographic, health-related, and policy covariates. We assessed effect modification by education and household income. RESULTS: Among 1489 participants, a $1.00 higher cigarette carton price was associated with a 16% higher likelihood of first smoking cessation (HR = 1.16, 95% CI = 1.11 to 1.21) and an 8% higher likelihood of sustained smoking cessation (HR = 1.08, 95% CI = 1.02 to 1.14). Associations were strongest among participants with lower income for first cessation, and among those with higher income for sustained cessation. Associations were strongest for participants with less than a high school degree for both outcomes. CONCLUSIONS: Results suggest higher cigarette prices promote smoking cessation among young to middle-aged adults, and that price sensitivity may differ by socioeconomic status. IMPLICATIONS: Few studies have examined longitudinal associations of cigarette prices with smoking cessation, and findings are mixed on whether price sensitivity varies by education or income. In a cohort of US adult daily smokers, cigarette prices were associated with greater likelihood of both a first cessation and sustained cessation. Price associations with first cessation were stronger among low-income smokers, but associations with sustained cessation were stronger among high-income smokers. Results suggest that although higher cigarette prices may promote short-term smoking cessation among smokers at all income levels, additional supports may be needed to facilitate sustained smoking cessation among low-income smokers.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study.

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Usability, Acceptability, and Impact of a Pediatric Teledermatology Mobile Health Application.

OBJECTIVE: Pediatric dermatology appointment wait times often exceed several months. We evaluated the usability, acceptability, and clinical impact of a store-and-forward teledermatology mobile application (app) linking families with pediatric dermatologists. METHODS: Parents of children age 6 weeks to 17 years or individuals 18-21 years old were invited (by e-mail or referral) to participate in this single group, prospective study. Within the app, users photographed the skin condition, answered questions, and submitted their case for review. One pediatric dermatologist viewed cases, diagnosed conditions, and provided instructions and prescriptions. User surveys immediately following app use and 1 week later, supplemented by electronic logs, assessed usability, acceptability, and impact. RESULTS: One hundred ninety-seven parents and one adolescent submitted cases within 39 days of invitation. App users were more likely to be white than those in the population invited (67% vs. 34%, p < 0.001) and their children were slightly younger (mean 7.3 vs. 9.0 years, p < 0.001). A majority, 83% found the app easy to use, 97% felt that submitting a case took "the right amount of time," 87% were satisfied, and 93% would use the app again. Prescription receipt was associated with increased app satisfaction (p = 0.008). The median user received a response in 2.8 h (interquartile range 1.1-6.4). Had the app been unavailable, 44% reported that they would have waited for primary care, 32% for a dermatology appointment, and 7% would have gone to an urgent care clinic. CONCLUSIONS: A mobile health app allowing families to directly consult a pediatric dermatologist was usable, acceptable, and expedited care.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans. METHODS: We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans. RESULTS: A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans. CONCLUSIONS: Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study.

BACKGROUND: Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established. OBJECTIVE: We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success. METHODS: We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework. RESULTS: We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success. CONCLUSIONS: Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children. CLINICALTRIAL: Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3).

Cumulative Health Vulnerabilities Among Adolescents by Age and Neighborhood Opportunity.

BACKGROUND AND OBJECTIVES: Early detection of health vulnerabilities in adolescents is integral to promoting healthy behaviors into adulthood. Our objective was to quantify the prevalence of health vulnerabilities among adolescents and examine differences by age and neighborhood opportunity. METHODS: In a cross-sectional analysis of electronic health record data for adolescents aged 13 to 18 years with preventive visits in a large pediatric primary care network between September 2021 and September 2022, we examined 5 health vulnerabilities: Tobacco use, substance use, firearm access, condomless intercourse, and depressive symptoms. Health vulnerabilities were assessed via self-reported adolescent health questionnaire and the validated Patient Health Questionnaire-Modified. Prevalence of health vulnerabilities were calculated alone and in combination, and compared by age and by quintile of neighborhood Child Opportunity Index (COI) score. Multivariable logistic regression estimated associations of neighborhood COI with reporting ≥2 health vulnerabilities. RESULTS: Among 40 197 adolescents (57.7% aged 13-15 years, 66.3% living in "high"/"very high" COI neighborhoods), 29.7% reported at least 1 health vulnerability and 7.9% reported ≥2 vulnerabilities. Cumulative health vulnerabilities were more prevalent among older adolescents and adolescents from lower opportunity neighborhoods. In adjusted models, lower COI was associated with 65% higher odds of having ≥2 vulnerabilities (odds ratio 1.65, 95% confidence interval 1.43-1.91) compared with adolescents from the highest COI quintile. CONCLUSIONS: Understanding the relationship between health vulnerabilities and neighborhood opportunities among adolescents may allow pediatric primary care providers and health systems to offer more tailored community support services and transdiagnostic specialized care navigation to address the health needs of teens with multiple vulnerabilities.

Trends and Persistent Disparities in Child Obesity During the COVID-19 Pandemic.

The COVID-19 pandemic has been associated with increases in pediatric obesity and widening pre-existing disparities. To better understand the pandemic's long-term impacts, we evaluated trends in obesity across different demographic groups during the pandemic through December 2022. Using a retrospective cohort design, we analyzed electronic health record data from a large pediatric primary care network. Logistic regression models fit using generalized estimating equations estimated odds ratios (ORs) for changes in the level and trajectory of obesity across 2-year month-matched periods: prepandemic (June 2017 to December 2019) and pandemic (June 2020 to December 2022). Among a cohort of 153,667 patients with visits in each period, there was a significant increase in the level of obesity at the pandemic onset [OR: 1.229, 95% confidence interval (CI): 1.211-1.247] followed by a significant decrease in the trend for obesity (OR: 0.993, 95% CI: 0.992-0.993). By December 2022, obesity had returned to prepandemic levels. However, persistent sociodemographic disparities remain.

Measures of Neighborhood Opportunity and Adherence to Recommended Pediatric Primary Care.

Importance: Neighborhood conditions are known to broadly impact child health. Research to date has not examined the association of the Childhood Opportunity Index (COI), a multidimensional indicator of neighborhood environment conditions, specifically with pediatric primary care outcomes. Objective: To determine the association of neighborhood opportunity measured by the COI with health metrics commonly captured clinically in pediatric primary care, reflecting both access to preventive care and child well-being. Design, Setting, and Participants: This cross-sectional observational study used electronic health record data from a large pediatric primary care network in the northeastern US. Participants included patients aged 0 to 19 years who were active in the primary care network between November 2020 and November 2022. Data were analyzed in December 2022. Exposure: Census tract-level COI overall score (in quintiles). Main Outcomes and Measures: Outcomes included up-to-date preventive care and immunization status and presence of obesity, adolescent depression and suicidality, and maternal depression and suicidality. Multivariable mixed-effects logistic regressions estimated associations of these outcomes with COI quintiles, adjusted for age, sex, race and ethnicity, and insurance type. Results: Among 338 277 patients (mean [SD] age, 9.8 [5.9] years; 165 223 female [48.8%]; 158 054 [46.7%] non-Hispanic White, 209 482 [61.9%] commercially insured), 81 739 (24.2%) and 130 361 (38.5%) lived in neighborhoods of very low and very high COI, respectively. Living in very high COI neighborhoods (vs very low COI) was associated with higher odds of being up-to-date on preventive visits (odds ratio [OR], 1.40; 95% CI, 1.32-1.48) and immunizations (OR, 1.77; 95% CI, 1.58-2.00), and with lower odds of obesity (OR, 0.55; 95% CI, 0.52-0.58), adolescent depression (OR, 0.78; 95% CI, 0.72-0.84) and suicidality (OR, 0.79; 95% CI, 0.73-0.85), and maternal depression (OR, 0.78; 95% CI, 0.72-0.86) and suicidality (OR, 0.71; 95% CI, 0.61-0.83). Conclusions and Relevance: This cross-sectional study of electronic health record data found that neighborhood opportunity was associated with multiple pediatric primary care outcomes. Understanding these associations can help health systems identify neighborhoods that need additional support and advocate for and develop partnerships with community groups to promote child well-being. The findings underscore the importance of improving access to preventive care in low COI communities.

Neighborhood Greenspace and Changes in Pediatric Obesity During COVID-19.

INTRODUCTION: Pediatric obesity rates increased during the COVID-19 pandemic. This study examined the associations of neighborhood greenspace with changes in pediatric obesity during the pandemic. METHODS: Electronic health record data from a large pediatric primary care network were extracted to create a retrospective cohort of patients aged 2-17 years with a visit in each of 2 periods: June 2019-December 2019 (before pandemic) and June 2020-December 2020 (pandemic). Multivariable longitudinal generalized estimating equations Poisson regression estimated the associations of census tract‒level Normalized Difference Vegetation Index with (1) changes in obesity risk during the pandemic and (2) risk of new-onset obesity among children who were not obese prepandemic. Analyses were conducted between November 2021 and May 2022. RESULTS: Among 81,418 children (mean age: 8.4 years, 18% Black), the percentage of children who were obese increased by 3.2% during the pandemic. Children in Normalized Difference Vegetation Index Quartiles 2-4 had smaller increases in obesity risk during the pandemic than those in Quartile 1 (risk ratio=0.96, 95% CI=0.93, 0.99; Quartile 3 risk ratio=0.95; 95% CI=0.91, 0.98; Quartile 4 risk ratio=0.95, 95% CI=0.92, 0.99). Among the subset who were not obese before the pandemic, children in Normalized Difference Vegetation Index quartiles 3-4 had a lower risk of new-onset obesity during the pandemic (Quartile 3 risk ratio=0.82, 95% CI=0.71, 0.95; Quartile 4 risk ratio=0.73, 95% CI=0.62, 0.85). Higher Normalized Difference Vegetation Index was associated with smaller increases in obesity risk and lower risk of new-onset obesity among children in urban and suburban areas, but results were in the opposite direction for children in rural areas. CONCLUSIONS: Children living in greener neighborhoods experienced smaller increases in obesity during the pandemic than children in less green neighborhoods, although findings differed by urbanicity.

The neighborhood environment and sleep health in adolescents.

OBJECTIVE: Neighborhood-level factors, including education, health and environment, and socioeconomic exposures, are important contextual determinants of child health. We explored whether these factors, measured via the Childhood Opportunity Index 2.0, were associated with sleep health in adolescents. METHODS: Actigraphy was used to assess sleep duration, timing, and efficiency among 110 adolescents in eighth (13.9 (0.4)) and ninth (14.9 (0.4)) grade. Home addresses were geocoded and linked to Childhood Opportunity Index 2.0 scores (including 3 subtype scores and the 29 individual factor Z-scores). Mixed-effects linear regression was used to determine associations between the Childhood Opportunity Index 2.0 scores and the sleep outcomes, adjusting for sex, race, parent education, household income, school grade and weeknight status. Interactions were also tested by school grade, weeknight status, sex, and race. RESULTS: No associations were observed between overall or subtype scores with sleep outcomes in adolescents. However, we detected associations between select individual Childhood Opportunity Index 2.0 Z-scores, spanning health & environment and education domains, and sleep outcomes. For example, greater fine particulate matter was associated with later timing of sleep onset and offset; ozone concentration was associated with earlier sleep onset and offset; greater exposure to extreme temperature was associated with later sleep onset and offset and increased odds of optimal sleep efficiency. CONCLUSIONS: Specific neighborhood factors indexed by the Childhood Opportunity Index 2.0 were associated with sleep health among adolescents. In particular, neighborhood air quality measures were associated with sleep timing and efficiency, warranting further investigation.

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19.

OBJECTIVE: Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022. METHODS: Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice. RESULTS: Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%). CONCLUSIONS: During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

Feasibility and acceptability of mobile methods to assess home and neighborhood environments related to adolescent sleep.

OBJECTIVE: A growing evidence base suggests home and neighborhood environmental exposures may influence adolescent sleep, but few studies have assessed these relationships using methods that account for time-varying, location-specific exposures, or multiple neighborhood contexts. This study aimed to assess the feasibility and acceptability of using smartphone global positioning system (GPS) tracking and ecological momentary assessment (EMA) to assess time-varying home and neighborhood environmental exposures hypothesized to be associated with adolescent sleep. METHODS: Adolescents aged 15-17 years in Philadelphia completed 7 days of continuous smartphone GPS tracking, which was used to identify daily levels of exposure to geocoded neighborhood factors (eg, crime, green space). Four daily EMA surveys assessed home sleep environment (eg, noise, light), stress, health behaviors, and neighborhood perceptions. Feasibility and acceptability of GPS tracking and EMA were assessed, and distributions of daily environmental exposures were examined. RESULTS: Among 25 teens (mean age 16, 56% male), there was a high level of GPS location data captured (median daily follow-up: 24 hours). Seventy-eight percent of EMA surveys were completed overall. Most participants (96%) reported no privacy concerns related to GPS tracking and minimal burden from EMA surveys. Exposures differed between participants' home neighborhoods and locations visited outside the home neighborhood (eg, higher crime away from home). Sleep environment disruptions were present on 29% of nights (most common: uncomfortable temperature) and were reported by 52% of adolescents. CONCLUSIONS: Results demonstrate the feasibility and acceptability of mobile methods for assessing time-varying home and neighborhood exposures relevant to adolescent sleep for up to 1 week.

Associations Between Food Insecurity and Neighborhood Safety, Social Cohesion, Social Control, and Crime Among Mothers of Preschool-Aged Children.

Food insecurity has myriad associations with poor health, and low-income communities have higher than average prevalence of food insecurity. Living in a supportive neighborhood social environment may protect against food insecurity, while adverse neighborhood social conditions, such as crime, may increase the likelihood of food insecurity. To examine associations between food insecurity and neighborhood social factors among families with young children, we administered a cross-sectional survey to 300 mothers and female caregivers of Medicaid-enrolled two- to four-year-old children in Philadelphia. We used multivariable regression to examine associations between food insecurity and perceived neighborhood safety, social cohesion, informal social control, and crime, adjusted for demographics, socioeconomic status, and neighborhood characteristics. Lower food insecurity prevalence was associated with higher perceived neighborhood safety and social cohesion, and lower police-recorded violent crime rates. Future work to increase food security among low-income households may benefit from targeting the neighborhood social environment.

Association of Neighborhood Social Context and Perceived Stress Among Mothers of Young Children.

BACKGROUND: Chronic parental stress may negatively impact health among both parents and children. Adverse neighborhood social conditions like crime may increase stress while a supportive neighborhood may buffer stress and promote well-being. Our objective was to examine associations between neighborhood social factors and stress among mothers of young children. METHODS: We surveyed 300 mothers/female caregivers of Medicaid-enrolled 2 to 4-year-old children in Philadelphia. Maternal stress was measured via the 10-item Perceived Stress Scale (range 0-40). Mothers' perceived neighborhood safety and collective efficacy were assessed using validated scales. Addresses were geocoded to link census tract-level violent crime rates. We used multivariable linear regression to examine associations of neighborhood safety, collective efficacy, and crime with maternal stress, adjusted for demographics, household socioeconomic status, and neighborhood poverty. RESULTS: Among mothers (mean age 31, 60% Black/African American), higher perceived neighborhood safety and collective efficacy were associated with lower stress scores after adjustment for covariates. Each 1-point increase (on a 5-point scale) in perceived neighborhood safety was associated with a 2.30-point decrease in maternal stress (95% CI: -3.07, -1.53). Similarly, each 1-point increase in perceived collective efficacy was associated with a 3.08-point decrease in maternal stress (95% CI: -4.13, -2.02). Police-recorded violent crime rates were not associated with maternal stress. CONCLUSION: Mothers of young children who perceive their neighborhood social environment more favorably report less stress compared to those who feel their neighborhood environment is less safe and cohesive. Future work is warranted to investigate whether interventions that increase perceived neighborhood safety and collective efficacy reduce stress.

Associations of Neighborhood Safety and Collective Efficacy with Dietary Intake among Preschool-Aged Children and Mothers.

Background: Positive neighborhood environments may promote healthier behaviors, yet few studies have examined associations between neighborhood social environment and diet. We examined associations of neighborhood perceived safety, collective efficacy, and violent crime with dietary intake among preschool-aged children and their mothers. Methods: We administered a cross-sectional survey to 300 mothers/female caregivers of Medicaid-enrolled 2- to 4-year-old children in Philadelphia. Mothers reported their own and their child's dietary intake using the validated Dietary Screener Questionnaire. Mixed-effects linear regression models assessed associations of perceived neighborhood safety, collective efficacy, and census tract-level violent crime with parent and child dietary intake, adjusted for individual, family, and neighborhood covariates. Results: Among mothers, higher perceived neighborhood safety and collective efficacy were associated with higher daily intake of fruits/vegetables (ß = 0.35 cups, 95% CI: 0.12-0.58 and ß = 0.30 cups, 95% CI: 0.08-0.52, comparing the highest with lowest tertile). Higher neighborhood-perceived safety was also associated with higher whole-grain intake among mothers (ß = 0.14 ounces, 95% CI: 0.02-0.27) and children (ß = 0.07 ounces, 95% CI: 0.01-0.13, comparing the highest with lowest tertile). Neighborhood social exposures were not associated with intake of added sugars or sugar-sweetened beverages for mothers or children, nor were lower levels of violent crime associated with any outcome. Conclusions: More favorable perceptions of neighborhood safety and collective efficacy were associated with a slightly higher consumption of some healthy foods among mothers and their young children. Future prospective research is needed to confirm these findings, explore potential mechanisms, and determine whether intervening on the social environment improves diet.

Exposure to Neighborhood-Level Racial Residential Segregation in Young Adulthood to Midlife and Incident Subclinical Atherosclerosis in Black Adults: The Coronary Artery Risk Development in Young Adults Study.

BACKGROUND: Neighborhood-level racial residential segregation has been linked to several cardiovascular disease risk factors and outcomes in Black adults, but its impact on subclinical atherosclerosis remains unknown. In addition, although the impact of segregation on health may vary over the life course, most studies have examined segregation exposure at a single point in time. This article takes a life course approach by examining associations of exposure to neighborhood-level racial residential segregation in young adulthood and patterns of exposure from young adulthood to midlife with coronary artery calcification (CAC) incidence. METHODS: We used data on 1125 Black CARDIA study (Coronary Artery Risk Development in Young Adults) participants free of CAC. Residential segregation was assessed using the Gi* statistic and measured when participants were young adults (18-30 years old, in 1985-1986) and as the pattern from young adulthood to midlife (15 years later). Poisson regression with generalized estimating equations models was used to measure CAC incidence. RESULTS: We found participants living in low segregation neighborhoods in young adulthood had 0.52 (rate ratio [95% CI: 0.28-0.98]) times lower risk of developing CAC compared with high segregation after adjusting for young adulthood sociodemographic characteristics and neighborhood poverty. Associations were attenuated and no longer statistically significant with adjustment for midlife CAC risk factors hypothesized to be on the causal pathway (rate ratio: 0.56 [95% CI: 0.29-1.09]). Findings for patterns of segregation over time suggest participants living in low segregation neighborhoods in young adulthood were less likely to develop CAC than those who started out in medium/high segregation neighborhoods, regardless of where they lived in midlife (rate ratio for increase from low to medium/high: 0.42 [95% CI: 0.19-0.95]; rate ratio for continuously low versus continuously medium/high segregation neighborhoods: 0.75 [95% CI: 0.31-1.83]). CONCLUSIONS: We found that participants living in more segregated neighborhoods in young adulthood were more likely to develop CAC due at least in part to differences in CAC risk factor burden accumulated over follow-up.

Neighborhood environments and sleep among children and adolescents: A systematic review.

Understanding salient environmental determinants of pediatric sleep is essential for informing interventions and public health initiatives. Emerging evidence suggests that the neighborhood environment can impact pediatric sleep, but this evidence has not yet been systematically reviewed. We conducted a systematic review of the scientific literature on associations between neighborhood environments and sleep in young children (0-5 y), school-aged children (6-12 y) and adolescents (13-18 y). We reviewed 85 articles published between 2003 and 2020. The most commonly examined neighborhood exposure was low socioeconomic status (40 studies), which was associated with sleep outcomes in 58% of studies (primarily shorter sleep duration, later sleep timing, or obstructive sleep apnea). Evidence was stronger for neighborhood safety/crime/violence (21 studies), with 86% of studies reporting associations with sleep outcomes (primarily self- or caregiver-reported sleep problems). Fewer studies examined associations of neighborhood physical environment exposures, including noise (15 studies), the built environment (seven studies), and air pollution (six studies). Limitations of the current body of evidence include 1) limited examination of neighborhood exposures other than socioeconomic status or safety, 2) use of primarily cross-sectional observational study designs, 3) lack of objective sleep outcome assessment, and 4) limits of current exposure assessment methods.