State Policies that Impact the Design of Children's Mental Health Services: A Modified Delphi Study.

To identify the state-level policies and policy domains that state policymakers and advocates perceive as most important for positively impacting the use of children's mental health services (CMHS). We used a modified Delphi technique (i.e., two rounds of questionnaires and an interview) during Spring 2021 to elicit perceptions among state mental health agency officials and advocates (n = 28) from twelve states on state policies that impact the use of CMHS. Participants rated a list of pre-specified policies on a 7-point Likert scale (1 = not important, 7 = extremely important) in the following policy domains: insurance coverage and limits, mental health services, school and social. Participants added nine policies to the initial list of 24 policies. The "school" policy domain was perceived as the most important, while the "social" policy domain was perceived as the least important after the first questionnaire and the second most important policy domain after the second questionnaire. The individual policies perceived as most important were school-based mental health services, state mental health parity, and Medicaid reimbursement rates. Key stakeholders in CMHS should leverage this group of policies to understand the current policy landscape in their state and to identify gaps in policy domains and potential policy opportunities to create a more comprehensive system to address children's mental health from a holistic, evidence-based policymaking perspective.

Are there birth cohort effects in disparities in child obesity by maternal education?

BACKGROUND: Children belonging to the same birth cohort (i.e., born in the same year) experience shared exposure to a common obesity-related milieu during the critical early years of development-e.g., secular beliefs and feeding practices, adverse chemical exposures, food access and nutrition assistance policies-that set the stage for a shared trajectory of obesity as they mature. Fundamental cause theory suggests that inequitable distribution of recent efforts to stem the rise in child obesity may exacerbate cohort-based disparities over time. METHODS: Data were from electronic health records spanning 2007-2016 linked to birth records for children ages 2-19 years. We used hierarchical age-period-cohort models to investigate cohort effects on disparities in obesity related to maternal education. We hypothesized that maternal education-based disparities in prevalence of obesity would be larger among more recent birth cohorts. RESULTS: Sex-stratified models adjusted for race/ethnicity showed substantial obesity disparities by maternal education that were evident even at young ages: prevalence among children with maternal education < high school compared to maternal college degree was approximately three times as high among girls and twice as high among boys. For maternal education < high school, disparities compared to maternal college degree were higher in more recent birth cohorts. Among girls, this disparity cohort effect was evident at younger ages (at age 4, the disparity increased by 4 [0.1-8] percentage points per 5 birth years), while among boys it was larger at older ages (at age 16, the disparity increased by 7 [1-14] percentage points per 5 birth years). CONCLUSIONS: There may be widening maternal education-based disparities in child obesity by birth cohort at some ages.

Linking Data on Constituent Health with Elected Officials' Opinions: Associations Between Urban Health Disparities and Mayoral Officials' Beliefs About Health Disparities in Their Cities.

Policy Points Mayoral officials' opinions about the existence and fairness of health disparities in their city are positively associated with the magnitude of income-based life expectancy disparity in their city. Associations between mayoral officials' opinions about health disparities in their city and the magnitude of life expectancy disparity in their city are not moderated by the social or fiscal ideology of mayoral officials or the ideology of their constituents. Highly visible and publicized information about mortality disparities, such as that related to COVID-19 disparities, has potential to elevate elected officials' perceptions of the severity of health disparities and influence their opinions about the issue. CONTEXT: A substantive body of research has explored what factors influence elected officials' opinions about health issues. However, no studies have assessed the potential influence of the health of an elected official's constituents. We assessed whether the magnitude of income-based life expectancy disparity within a city was associated with the opinions of that city's mayoral official (i.e., mayor or deputy mayor) about health disparities in their city. METHODS: The independent variable was the magnitude of income-based life expectancy disparity in US cities. The magnitude was determined by linking 2010-2015 estimates of life expectancy and median household income for 8,434 census tracts in 224 cities. The dependent variables were mayoral officials' opinions from a 2016 survey about the existence and fairness of health disparities in their city (n = 224, response rate 30.3%). Multivariable logistic regression was used to adjust for characteristics of mayoral officials (e.g., ideology) and city characteristics. FINDINGS: In cities in the highest income-based life expectancy disparity quartile, 50.0% of mayoral officials "strongly agreed" that health disparities existed and 52.7% believed health disparities were "very unfair." In comparison, among mayoral officials in cities in the lowest disparity quartile 33.9% "strongly agreed" that health disparities existed and 22.2% believed the disparities were "very unfair." A 1-year-larger income-based life expectancy disparity in a city was associated with 25% higher odds that the city's mayoral official would "strongly agree" that health disparities existed (odds ratio [OR] = 1.25; P = .04) and twice the odds that the city's mayoral official would believe that such disparities were "very unfair" (OR = 2.24; P <.001). CONCLUSIONS: Mayoral officials' opinions about health disparities in their jurisdictions are generally aligned with, and potentially influenced by, information about the magnitude of income-based life expectancy disparities among their constituents.

State Legislators' Support for Behavioral Health Parity Laws: The Influence of Mutable and Fixed Factors at Multiple Levels.

Policy Points When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators' opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state-level contextual factors. Reducing legislators' stigma toward people with mental illness could increase their support for state behavioral health parity laws CONTEXT: Comprehensive state behavioral health parity legislation (C-SBHPL) is an evidence-based policy that improves access and adherence to behavioral health treatments. However, adoption of C-SBHPL by state legislators is low. Little is known about how C-SBHPL evidence might be most effectively disseminated to legislators or how legislators' fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state-level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators' fixed and mutable characteristics, state-level contextual factors, and support for C-SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C-SBHPL support. METHODS: We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C-SBHPL, and the independent variables included legislators' fixed and mutable characteristics and state-level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression. FINDINGS: Thirty-nine percent of the legislators strongly supported C-SBHPL. After adjustment, the strongest predictors of C-SBHPL support were beliefs that C-SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C-SBHPL. State-level contextual factors did not moderate associations between mutable characteristics and support for C-SBHPL. CONCLUSIONS: Legislators' mutable characteristics are stronger predictors of C-SBHPL support than are most of their fixed characteristics and all state-level contextual factors, and thus should be targeted by dissemination efforts.

Child and Adult Socioeconomic Status and the Cortisol Response to Acute Stress: Evidence From the Multi-Ethnic Study of Atherosclerosis.

OBJECTIVE: A long-hypothesized pathway through which low socioeconomic status (SES) harms health is through dysregulation of the physiologic stress response systems. No previous studies have tested this hypothesis by investigating cortisol reactivity and recovery to acute stress in relation to SES at different times in the life course in adults. Alteration of the cortisol response to an acute stressor could signal dysregulation of the hypothalamic-pituitary-adrenal axis and has been associated with chronic illness. METHODS: We used data on 997 adults 54 years or older from a multiethnic, multisite United States study to examine associations between life course SES and cortisol response to a laboratory stress challenge. Informed by life course theory, we hypothesized that lower child and adult SES would be associated with lower reactivity (i.e., smaller increase in cortisol) and a slower recovery rate (i.e., slower rate of decline in cortisol after the challenge). RESULTS: In demographics-adjusted multilevel piecewise linear regression models, low child and adult SES were associated with a 19% (95% CI = 4%-50%) and 27% (7%-55%) slower recovery rate compared with high child and adult SES, respectively. Compared with participants with stable high SES, those with stable low SES had a 48% (16%-70%) slower recovery rate. Differences in reactivity by SES were small. CONCLUSIONS: Our results support the hypothesis that low SES throughout life affects the hypothalamic-pituitary-adrenal axis and in turn the ability to recover from exposure to acute stressors. This mechanism can help explain how socioeconomic disparities contribute to disparities in chronic disease.

A Case Study of the Philadelphia Sugar-Sweetened Beverage Tax Policymaking Process: Implications for Policy Development and Advocacy.

CONTEXT: Policymakers are increasingly proposing sugar-sweetened beverage (SSB) taxes as an evidence-based strategy to reduce chronic disease risk; and local health departments (LHDs) are well-positioned to play a role in SSB policy development and advocacy. However, most SSB tax proposals fail to become law and limited empiric guidance exists to inform advocacy efforts. In June 2016, Philadelphia, Pennsylvania, passed an SSB tax. OBJECTIVE: To identify features of the Philadelphia SSB tax policymaking process that contributed to the proposal's passage. DESIGN: Qualitative case study. Semistructured interviews were conducted with key informants closely involved with the policymaking process. Interviews were audio-recorded and transcribed. Local news media about the SSB tax proposal were analyzed to triangulate interview findings. Analysis was conducted in NVivo 10 using inductive qualitative content analysis. SETTING: Philadelphia, Pennsylvania, during the SSB tax policymaking in process. PARTICIPANTS: Nine key informants (2 city councilpersons, 4 city agency officials, 1 community-based advocate, 1 news reporter, and 1 researcher). RESULTS: The Philadelphia SSB tax proposal was introduced with the explicit goal of financing universal prekindergarten and deliberately not framed as a health intervention. This framing shifted contentious debates about government involvement in individual behavior toward discussions about how to finance universal prekindergarten, a goal for which broad support existed. The LHD played an important role in communicating research evidence about potential health benefits of the SSB tax proposal at the end of the policymaking process. CONCLUSIONS: During local SSB tax policy development processes, LHD officials and other advocates should encourage policymakers to design SSB tax policies so that revenue is directed toward community investments for which broad public support exists. When communicating with policymakers and the public, LHDs should consider emphasizing how SSB tax revenue will be used in addition to presenting evidence about the potential health benefits of the SSB tax at the local level.

The Affordable Care Act Reduces Hypertension Treatment Disparities for Mexican-heritage Latinos.

OBJECTIVES: Mexican-heritage Latinos have lower prevalence of hypertension, but have worse patterns of treatment and control compared with non-Latino whites. This study examined the impact of the Affordable Care Act (ACA) insurance expansion on reducing disparities in treatment and medication use among Mexican-heritage Latinos with hypertension. RESEARCH DESIGN: Using the 2009-2014 waves of the California Health Interview Survey, we examine health care access, utilization, and medication use among Mexican-heritage Latinos and non-Latino whites with hypertension. Multivariable logistic regression analyses were performed to adjust for socioeconomic and demographic factors. Interactions between race/ethnicity and year variables were conducted to capture the effects of the passage of the ACA. RESULTS: Among those with hypertension, the full implementation of the ACA (year 2014) is associated with a greater likelihood of being insured, but the race/ethnicity interaction indicates that this gain is less substantial for Mexican-heritage Latinos. The odds of having a usual source of care other than the emergency department increased after the passage of the ACA, and interaction effects indicate that this gain was more substantial for Mexican-heritage Latinos. The odds of having any physician visit and taking blood pressure mediations decreased among non-Latino whites but increased among Mexican-heritage Latinos. CONCLUSIONS: The implementation of the ACA in California has helped reduce some of the disparities in health care access, utilization, and medication use between non-Latino whites and Mexican-heritage Latinos with hypertension. However, sustained progress is threatened by looming repeals of ACA provisions.

Funding quality pre-kindergarten slots with Philadelphia's new 'sugary drink tax': simulating effects of using an excise tax to address a social determinant of health.

OBJECTIVE: Philadelphia passed a 1·5-cent-per-ounce sweetened beverage tax (SBT). Revenue will fund 10 000 quality pre-kindergarten slots for poor children. It is imperative to understand how revenue from SBT can be used to fund programmes to address education and other social determinants of health. The objective of the present study was to simulate quality pre-kindergarten attendance, educational achievement and sugar-sweetened beverage (SSB) consumption among Philadelphia children and adolescents under six intervention scenarios: (i) no intervention; (ii) 10 000 additional quality pre-kindergarten slots; (iii) a 1·5-cent-per-ounce SBT; (iv) expanded pre-kindergarten and 1·5-cent-per-ounce SBT; (v) a 3-cent-per-ounce SBT; and (vi) expanded pre-kindergarten and 3-cent-per-ounce SBT. DESIGN: We used an agent-based model to estimate pre-kindergarten enrolment, educational achievement and SSB consumption under the six policy scenarios. We identified key parameters in the model from the published literature and secondary analyses of the Panel Study of Income Dynamics - Child Development Supplement. SETTING: Philadelphia, Pennsylvania, USA. SUBJECTS: Philadelphia children and adolescents aged 4-18 years. RESULTS: A 1·5-cents-per-ounce tax would reduce SSB consumption by 1·3 drinks/week among Philadelphia children and adolescents relative to no intervention, with larger effects among children below the poverty level. Quality pre-kindergarten expansion magnifies the effect of the SBT by 8 %, but has the largest effect on moderate-income children just above the poverty level. The SBT and quality pre-kindergarten programme each reduce SSB consumption, but primarily benefit different children and adolescents. CONCLUSIONS: Pairing an excise tax with a complementary programme to improve a social determinant of health represents a progressive strategy to combat obesity, a disease regressive in its social patterning.

Invited Commentary: Multigenerational Social Determinants of Health­Opportunities and Challenges.

An emerging area of social epidemiology examines the relationship between grandparental education and grandchild health. In an accompanying article, Huang et al. (Am J Epidemiol. 2015;182(7):568-578) join the small but growing body of research on this topic. It is useful to contextualize Huang et al.'s work within the much larger body of research examining relationships between education and health within a single generation or across 2 generations. These investigators have generally concluded that higher educational attainment is robustly associated with better health. There are many potential mechanisms through which education and other social exposures may affect health outcomes in a single generation or across generations, and estimating direct and indirect effects can be helpful for assessing specific mechanisms. Researchers conducting multigenerational analyses are faced with several challenges, including limited availability of data for some measures (e.g., educational attainment, and sometimes for 1 grandparent only), limited age ranges of participants, disparate social and political contexts in which study participants of different generations have lived, and patterns of social class reproduction. We encourage future researchers to weave together the careful analytical considerations illustrated by Huang et al. with a rich understanding of the social context for each of the generations studied to help overcome these challenges and advance our understanding of multigenerational social determinants of health.

Associations of grandparental schooling with adult grandchildren's health status, smoking, and obesity.

Despite persistent schooling-related health disparities in the United States, little is known about the multigenerational effects of schooling on adult health. As expected lifespans increase, direct influences of grandparental schooling on grandchildren's health may become increasingly important. We used multigenerational data spanning 41 years from a national sample of US families to investigate associations of grandparents' educational attainment with global health status, smoking, and obesity in their grandchildren who were aged 25-55 years in 2009. We estimated total effects of grandparental schooling and, by using marginal structural models, we estimated controlled direct effects that were independent of parents' and participants' schooling. Among whites, lower levels of grandparental schooling were monotonically associated with poor health status, current smoking, and obesity in adult grandchildren. There was also evidence suggesting direct effects, which was stronger for poor health status among participants whose highest-educated grandparent lived in the same state. Among blacks, the only association suggesting a total or direct effect of grandparental schooling was for smoking. Despite the relative imprecision of our estimates and possible residual bias, these results suggest that higher levels of grandparental schooling may benefit the health of grandchildren in adulthood, especially among whites. Furthermore, part of those apparent effects, especially for obesity, may not be mediated by parents' and grandchildren's schooling.

Neighborhood ethnic composition, spatial assimilation, and change in body mass index over time among Hispanic and Chinese immigrants: Multi-Ethnic Study of Atherosclerosis.

OBJECTIVES: We investigated relations between changes in neighborhood ethnic composition and changes in body mass index (BMI) and waist circumference among Chinese and Hispanic immigrants in the United States. METHODS: We used Multi-Ethnic Study of Atherosclerosis data over a median 9-year follow-up (2000-2002 to 2010-2012) among Chinese (n = 642) and Hispanic (n = 784) immigrants aged 45 to 84 years at baseline. We incorporated information about residential moves and used econometric fixed-effects models to control for confounding by time-invariant characteristics. We characterized neighborhood racial/ethnic composition with census tract-level percentage Asian for Chinese participants and percentage Hispanic for Hispanic participants (neighborhood coethnic concentration). RESULTS: In covariate-adjusted longitudinal fixed-effects models, results suggested associations between decreasing neighborhood coethnic concentration and increasing weight, although results were imprecise: within-person BMI increases associated with an interquartile range decrease in coethnic concentration were 0.15 kilograms per meters squared (95% confidence interval [CI] = 0.00, 0.30) among Chinese and 0.17 kilograms per meters squared (95% CI = -0.17, 0.51) among Hispanic participants. Results did not differ between those who did and did not move during follow-up. CONCLUSIONS: Residential neighborhoods may help shape chronic disease risk among immigrants.

A Short Adverse Experiences Measure Among Mothers of Young Children.

OBJECTIVES: Screening for parental adverse childhood experiences (ACEs) in pediatric settings can be burdensome because of the questionnaire's length and sensitive nature. Rapid screening tools may help address these challenges. We evaluated a 2-item short ACE measure developed for adults in a cross-sectional sample of mothers of young children in an urban pediatric emergency department. METHODS: From January 2011 to March 2020, we administered the ACE questionnaire in English or Spanish to 3999 biological mothers of children aged <4 years in a pediatric emergency department in Philadelphia, Pennsylvania. We assessed sensitivity and specificity of a shortened 2-item ACE measure defined as report of childhood emotional abuse and/or household substance use, using 4+ ACEs on the full questionnaire as the standard. We assessed convergent validity by comparing associations of the 2-item and standard measures with maternal, household, and child outcomes using adjusted log-binomial regression. RESULTS: Mothers were racially and ethnically diverse (54% Latina, 35% Black non-Latina); 94% of children were publicly insured. Thirteen percent of mothers reported childhood emotional abuse and 16% childhood household substance use; 23% reported at least 1 of these and 6% both. Compared with 4+ ACEs on the full questionnaire, the 2-item measure had sensitivity 88% and specificity 90%. In adjusted models, high adversity was associated with poor maternal, household, and child outcomes. CONCLUSIONS: A 2-item ACE measure assessing childhood emotional abuse and household substance use may be useful in pediatric settings to identify mothers who may have experienced significant child adversity and inform development, testing, or provision of comprehensive family supports.

Moving Because of Unaffordable Housing and Disrupted Social Safety Net Access Among Children.

OBJECTIVES: To measure associations between residential moves because of unaffordable housing costs and disruptions in access to the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and Medicaid in a health care-based sample of families with young children. METHODS: We used cross-sectional survey data on social safety net-eligible caregivers and children recruited into the Children's HealthWatch study from emergency departments and primary care clinics in Baltimore and Philadelphia (2011-2019). Children's HealthWatch measured residential moves (cost-driven and noncost-driven) in the past year and disruptions in safety net access. We used logistic regression to estimate associations between each type of move and disrupted access to social safety nets. RESULTS: Across 9344 children, cost-driven residential moves were associated with higher odds of disrupted access to at least 1 safety net program (Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; or Medicaid; adjusted odds ratio 1.44; 95% confidence interval 1.16-1.80), as well as higher odds of disruption to each program separately. Noncost-driven moves were also associated with disruptions to at least 1 safety net program, but less strongly so (adjusted odds ratio 1.14; confidence interval 1.01-1.29; P value for comparison with cost-driven = .045). CONCLUSIONS: Residential moves, particularly cost-driven moves, are associated with social safety net benefit disruptions. The association between these events suggests a need for action to ensure consistent safety net access among children facing cost-driven moves and vice versa (ie, access to housing supports for children with disrupted safety net access).

Unintended consequences of disseminating behavioral health evidence to policymakers: Results from a survey-based experiment.

Background: Communication research demonstrates that messages often have unintended consequences, but this work has received limited attention in implementation science. This dissemination experiment sought to determine whether state-tailored policy briefs about the behavioral health consequences of adverse childhood experiences (ACEs), compared to national policy briefs on the topic, increased state legislators'/staffers' perceptions of the policy brief relevance and parental blame for the consequences of ACEs, and whether effects differed between Democrats and Republicans. Method: A preregistered, web-based survey experiment with U.S. state legislators/staffers was conducted in 2021 (n = 133). Respondents were randomized to view a policy brief about the behavioral health consequences of ACEs that included state-tailored data (intervention condition) or national data (control condition) and then answered survey questions. Dependent variables were perceived policy brief relevance and parental blame for the consequences of ACEs. Results: The mean policy brief relevance score was 4.1% higher in the intervention than in the control condition (p = .24), but the mean parental blame score was 16.5% higher (p = .02). When outcomes were dichotomized, 61.2% of respondents in the intervention condition rated parents as "very much to blame" for the consequences of ACEs compared to 37.1% in the control condition (p = .01). When the sample was stratified by political affiliation, the effect of the state-tailored policy brief on parental blame was larger in magnitude among Democrats and not significant among Republicans. The intervention policy brief increased the mean parental blame score by 22.8% among Democrats relative to the control policy brief (p = .007) and doubled the proportion rating parents as "very much to blame" (52.2% vs. 26.1%, p = .03). Conclusions: Despite limited statistical power, state-tailored policy briefs significantly increased state legislators'/staffers' perceptions of parental blame for the behavioral health consequences of ACEs, relative to a policy brief with national data. Unintended messaging effects warrant greater attention in dissemination research and practice.

Prior studies have tested the effects of dissemination strategies on policymakers' engagement with research evidence. However, little research has assessed the potential unintended consequences of disseminating evidence to policymakers. This knowledge gap is important because a large body of communication research has found that messages often have negative and unintended effects. This paper adds to the literature on disseminating evidence about behavioral health issues to policymakers. A web-based survey experiment was conducted in which U.S. state legislators/staffers were randomized to view a policy brief about adverse childhood experiences (ACEs) that was tailored to present data from their state (intervention condition) or a policy brief that presented national data and then completed a survey. Legislators/staffers who viewed the state-tailored policy brief perceived the brief as slightly more relevant, but also rated parents as being significantly more to blame for the behavioral health consequence of ACEs. The effect of the state-tailored policy brief on parental blame is an unintended messaging effect that signals cause for caution when disseminating evidence about ACEs to policymakers and other practice audiences. More broadly, the findings highlight a need to consider unintended messaging effects in dissemination research and practice.

Associations of longitudinal BMI percentile classification patterns in early childhood with neighborhood-level social determinants of health.

Background: Understanding social determinants of health (SDOH) that may be risk factors for childhood obesity is important to developing targeted interventions to prevent obesity. Prior studies have examined these risk factors, mostly examining obesity as a static outcome variable. Objectives: This study aimed to identify distinct subpopulations based on BMI percentile classification or changes in BMI percentile classifications over time and explore these longitudinal associations with neighborhood-level SDOH factors in children from 0 to 7 years of age. Methods: Using Latent Class Growth (Mixture) Modelling (LCGMM) we identify distinct BMI% classification groups in children from 0 to 7 years of age. We used multinomial logistic regression to study associations between SDOH factors with each BMI% classification group. Results: From the study cohort of 36,910 children, five distinct BMI% classification groups emerged: always having obesity (n=429; 1.16%), overweight most of the time (n=15,006; 40.65%), increasing BMI% (n=9,060; 24.54%), decreasing BMI% (n=5,058; 13.70%), and always normal weight (n=7,357; 19.89%). Compared to children in the decreasing BMI% and always normal weight groups, children in the other three groups were more likely to live in neighborhoods with higher rates of poverty, unemployment, crowded households, and single-parent households, and lower rates of preschool enrollment. Conclusions: Neighborhood-level SDOH factors have significant associations with children's BMI% classification and changes in classification over time. This highlights the need to develop tailored obesity interventions for different groups to address the barriers faced by communities that can impact the weight and health of the children living within them.

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

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

Association Between Material Hardship in Families With Young Children and Federal Relief Program Participation by Race and Ethnicity and Maternal Nativity.

Importance: Even brief periods of hardship during early childhood may have lifelong consequences. Prior cross-sectional research limited to respondents with English proficiency and internet access during the COVID-19 crisis documented families with young children that struggled to afford basic needs like food and rent. Few studies have examined experiences of families with young children by race and ethnicity and maternal nativity. Objective: To examine the association of COVID-19 relief programs with the mitigation of household food insecurity among families with young children, as well as being behind on rent and disparities in program receipt. Design, Setting, and Participants: This cohort study used data from the ongoing repeat cross-sectional Children's HealthWatch study comprising families surveyed at baseline (January 1, 2018, to March 20, 2020) and during the COVID-19 crisis (September 1, 2020, to June 30, 2021). Baseline questionnaires were administered face to face to caregivers of children aged 48 months or younger in English or Spanish in emergency departments or primary care clinics in 5 US cities. The follow-up questionnaires were administered via telephone. Exposures: Supplemental Nutrition Assistance Program (SNAP) participation or receipt of at least 1 Economic Impact Payment (EIP; ie, stimulus check) during the COVID-19 crisis. Main Outcomes and Measures: The primary outcomes were household food insecurity (assessed via the US Household Food Security Survey Module: Six-Item Short Form) and being behind on rent. Logistic and binomial regression models were used to calculate adjusted odds ratios (aORs) and unadjusted and adjusted prevalence ratios (PRs). Results: Of 1396 caregiver-child dyads (20.3% response rate), race and ethnicity data were available for 1357 caregivers: 514 (37.9%) were Black, non-Latino; 558 (41.1%) were Latino; 230 (16.9%) were White, non-Latino; and 55 (4.1%) were of other non-Latino race or ethnicity. Among 1390 responses with nonmissing data, 417 children (30.0%) had an immigrant mother, and among 1388 responses, 1238 (33.5%) were publicly insured. During the crisis, 467 of 1395 respondents (33.5%) reported household food insecurity, and 567 of 1391 respondents (40.8%) reported being behind on rent. Families with immigrant mothers had lower odds of EIP and SNAP participation than families with US-born mothers (eg, aOR, 0.07 [95% CI, 0.05-0.12] for both EIP and SNAP vs neither), despite being more likely to report household food insecurity (adjusted PR [aPR], 1.48 [95% CI, 1.28-1.71]) and being behind on rent (aPR, 1.14 [95% CI, 1.00-1.30]). Families with Black (unadjusted PR [uPR], 1.40 [95% CI, 1.08-1.82]) or Latino (uPR, 1.54 [95% CI, 1.19-1.98]) caregivers or caregivers of other race and ethnicity (uPR, 1.67 [1.12-2.49]) were also more likely than families with White, non-Latino caregivers to experience household food insecurity or being behind on rent (families with Black caregivers: uPR, 2.02 [95% CI, 1.58-2.58]; families with Latino caregivers: 1.68 [95% CI, 1.30-2.16]; families with caregivers of other race or ethnicity: uPR, 1.94 [95% CI, 1.34-2.80]). Adjustment for covariates and differential participation in relief programs did not entirely account for these disparities. Conclusions and Relevance: The results of this cohort study suggest that the COVID-19 crisis exacerbated preexisting inequities in food insecurity and difficulty paying rent according to race and ethnicity and maternal nativity and that equity-focused policy changes are needed to ensure that all children and their families in the US can afford basic needs for optimal health.

Research and Evaluation in a Child-Focused Place-Based Initiative: West Philly Promise Neighborhood.

Place-based initiatives attempt to reduce persistent health inequities through multisectoral, cross-system collaborations incorporating multiple interventions targeted at varying levels from individuals to systems. Evaluations of these initiatives may be thought of as part of the community change process itself with a focus on real-time learning and accountability. We described the design, implementation, challenges, and initial results of an evaluation of the West Philly Promise Neighborhood, which is a comprehensive, child-focused place-based initiative in Philadelphia, Pennsylvania. Priorities for the evaluation were to build processes for and a culture of ongoing data collection, monitoring, and communication, with a focus on transparency, accountability, and data democratization; establish systems to collect data at multiple levels, with a focus on multiple uses of the data and future sustainability; and adhere to grant requirements on data collection and reporting. Data collection activities included the compilation of neighborhood-level indicators; the implementation of a program-tracking system; administrative data linkage; and neighborhood, school, and organizational surveys. Baseline results pointed to existing strengths in the neighborhood, such as the overwhelming majority of caregivers reporting that they read to their young children (86.9%), while other indicators showed areas of need for additional supports and were programmatic focuses for the initiative (e.g., about one-quarter of young children were not engaged in an early childhood education setting). Results were communicated in multiple formats. Challenges included aligning timelines, the measurement of relationship-building and other process-focused outcomes, data and technology limitations, and administrative and legal barriers. Evaluation approaches and funding models that acknowledge the importance of capacity-building processes and allow the development and measurement of population-level outcomes in a realistic timeframe are critical for measuring the success of place-based approaches.

Associations of household unmet basic needs and health outcomes among very low birth weight children.

OBJECTIVE: We examined associations of past year household hardships (housing, energy, food, and healthcare hardships) with postnatal growth, developmental risk, health status, and hospitalization among children 0-36 months born with very low birth weight (VLBW) and the extent that these relationships differed by receipt of child supplemental security income (SSI). STUDY DESIGN: We examined cross-sectional data from 695 families. Growth was measured as weight-for-age z-score change. Developmental risk was defined as ≥1 concerns on the "Parents' Evaluation of Developmental Status" screening tool. Child health status was categorized as excellent/good vs. fair/poor. Hospitalizations excluded birth hospitalizations. RESULTS: Compared to children with no household hardships, odds of developmental risk were greater with 1 hardship (aOR 2.0 [1.26, 3.17]) and ≥2 hardships (aOR) 1.85 [1.18, 2.91], and odds of fair/poor child health (aOR) 1.59 [1.02, 2.49] and hospitalizations (aOR) 1.49 [1.00, 2.20] were greater among children with ≥2 hardships. In stratified analysis, associations of hardships and developmental risk were present for households with no child SSI and absent for households with child SSI. CONCLUSION: Household hardships were associated with developmental risk, fair/poor health status, and hospitalizations among VLBW children. Child SSI may be protective against developmental risk among children living in households with hardships.

Changes in Economic Hardships Arising During the COVID-19 Pandemic: Differences by Nativity and Race.

Hardships in early childhood impact health. Few longitudinal studies have examined pandemic-related hardships among families with young children by race/ethnicity or nativity. We used prospective longitudinal data from 1,165 caregivers of children < 4 years surveyed in English and Spanish face-to-face in 5 urban hospitals 1/2018 to 3/2020 (pre-pandemic) and again by telephone 9/2020 to 3/2021 (during pandemic). Caregivers reported hardships (household food insecurity [HFI], child food insecurity [CFI]), behind on rent [BOR]) and maternal race/ethnicity and nativity. During the pandemic vs pre-pandemic, families with immigrant mothers had greater increases in HFI [aOR = 2.15 (CI 1.49-3.09)] than families with US-born mothers [aOR = 1.44 (CI 1.09-1.90)] and greater increases in BOR [families with immigrant mothers aOR = 4.09 (CI 2.78-6.01) vs. families with US-born mothers aOR = 2.19 (CI 1.68-2.85)]. CFI increases for all groups did not vary by nativity nor race/ethnicity. HFI and BOR increases during COVID were significantly greater in families with Latina mothers and those with immigrant mothers than other groups.