Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births.

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Complex relationships between vitamin D and allergic sensitization among Puerto Rican 2-year-old children.

BACKGROUND: In the United States, Puerto Ricans have a higher prevalence of asthma than other Latino ethnicities. Low vitamin D levels for children living in northern climates could be a factor. OBJECTIVE: To assess serum 25-hydroxyvitamin D [25(OH)D] distributions (a marker of vitamin D) and associations among vitamin D, allergic sensitization, early wheeze, and home/demographic factors. METHODS: Puerto Rican infants born in New York City, with a maternal history of atopy, were enrolled in a birth cohort. Blood was collected at age 2 years (n = 154; 82 males and 72 females). Serum 25(OH)D and immunoglobulin E (IgE) (indoor allergen-specific and total) were determined using immunoassays. Home/demographic characteristics and respiratory symptoms were assessed by questionnaire. RESULTS: The median concentration of 25(OH)D was 22.6 ng/mL; 32% were at risk of deficiency or inadequacy (<12 or 12-19 ng/mL). Serum 25(OH)D levels were lower in the heating (a surrogate for less sun exposure in colder months) compared with nonheating (26.1 vs 22.7 ng/mL, P = .02) season, but were not associated with allergen-specific IgE levels or with level of acculturation (measured by maternal birthplace). However, low 25(OH)D levels (below median) were associated with high total IgE >100 IU/mL (P = .01). Also, 25(OH)D concentrations differed between children who attended daycare and those who did not (21.8 vs 24.5 ng/mL; t test, P = .02). Serum 25(OH)D was not associated with wheeze or asthma by 2 years of age (P = .43). CONCLUSION: Vitamin D deficiency, possibly linked with allergic pathways, may partially explain the trajectory for disproportionate asthma burden among Puerto Ricans, especially those born and raised in colder climates.

The effects of a housing mobility experiment on participants' residential environments.

We used the Moving to Opportunity (MTO) housing experiment to inform how housing choice vouchers and housing mobility policies can assist families living in high-poverty areas to make opportunity moves to higher quality neighborhoods, across a wide range of neighborhood attributes. We compared the neighborhood attainment of the three randomly-assigned MTO treatment groups (Low Poverty voucher, Section 8 voucher, Control group) at 1997 and 2002 locations (4-7 years after baseline), by using survey reports, and by linking residential histories to numerous different administrative and population-based datasets. Compared to controls, families in Low-Poverty and Section 8 groups experienced substantial improvements in neighborhood conditions across diverse measures, including economic conditions, social systems (e.g., collective efficacy), physical features of the environment (e.g., tree cover) and health outcomes. The Low-poverty voucher group moreover achieved better neighborhood attainment compared to Section 8. Treatment effects were largest for New York and Los Angeles. We discuss the implications of our findings for expanding affordable housing policy.

Future directions in research on institutional and interpersonal discrimination and children's health.

Research evidence indicates that 2 forms of racial discrimination-perceived interpersonal discrimination and racial/ethnic residential segregation (a form of institutional discrimination)-may influence children's health and disparities. Although research on these 2 forms of discrimination and health has primarily focused on adults, smaller bodies of work have documented that perceived interpersonal discrimination and segregation have a negative effect on infants' health, and that perceived interpersonal discrimination may negatively affect children's mental health. Three directions for research are (1) incorporating a life-course perspective into studies of discrimination and children's health, (2) linking residential segregation with geography-of-opportunity conceptual frameworks and measures, and (3) considering residential segregation along with segregation in other contexts that influence children's health (e.g., schools).

Sociocultural characteristics, obesity and inflammatory biomarkers in Puerto Rican toddlers born in New York City.

BACKGROUND: In the USA, Puerto Rican children have a higher prevalence of asthma than other Latino ethnicities, and acculturation is one of hypothesized reasons for this difference. We examined associations between sociocultural characteristics and serum leptin, high-sensitivity C-reactive protein (hsCRP), and body mass index (BMI), and further, among hsCRP, leptin levels, BMI percentiles, and allergic sensitization in 2-year-old children. METHODS: IgE antibodies, leptin, and hsCRP concentrations were measured in serum from Puerto Rican toddlers (n = 143) born in New York City with a maternal history of allergy and/or asthma. Demographic and home characteristics questionnaires were administered to the mother, postpartum and two years later. Children's weight and height were measured to determine BMI percentiles. RESULTS: More girls (60%) had leptin levels above the median compared with boys (37%) (p = 0.0063). Leptin was positively correlated with BMI (r = 0.25; p = 0.0042). Children in daycare were more likely to be obese (40% vs. 24% p < 0.06). Maternal birthplace was significantly associated with children's leptin but not with hsCRP. Leptin levels were lower for children whose mothers were born on the US mainland (GM = 2.5 ng/ml, 95% CI [2.2-2.7]) compared with those whose mothers were born in Puerto Rico or another country (GM = 3.2 ng/ml, 95% CI [2.2-3.9], t-test p = 0.01). Mothers born in another country were more likely than those born in the US mainland or Puerto Rico to have obese children (60% vs. 26% p < 0.02). Leptin, hsCRP, and BMI percentile were not associated with sensitization to any of the measured inhalant allergens or total IgE. CONCLUSION: Even at a very young age, some acculturation factors were associated with biomarkers and anthropometric measures of obesity among this Puerto Rican pediatric population. To our knowledge, this is the first study demonstrating the association of mother's birth place with child BMI and leptin as early as 24 months.

Neighborhood Opportunity and Mortality Among Children and Adults in Their Households.

BACKGROUND AND OBJECTIVES: Research has linked neighborhood opportunity to health outcomes in children and adults; however, few studies have examined neighborhood opportunity and mortality risk among children and their caregivers. The objective of this study was to assess associations of neighborhood opportunity and mortality risk in children and their caregivers over 11 years. METHODS: Participants included 1 025 000 children drawn from the Mortality Disparities in American Communities study, a cohort developed by linking the 2008 American Community Survey to the National Death Index and followed for 11 years. Neighborhood opportunity was measured using the Child Opportunity Index, a measure designed to capture compounding inequities in access to opportunities for health. RESULTS: Using hazard models, we observed inverse associations between Child Opportunity Index quintile and deaths among child and caregivers. Children in very low opportunity neighborhoods at baseline had 1.30 times the risk of dying over follow-up relative to those in very high opportunity neighborhoods (95% confidence interval [CI], 1.15-1.45), and this excess risk attenuated after adjustment for household characteristics (hazard ratio, 1.15; 95% CI, 0.98-1.34). Similarly, children in very low opportunity neighborhoods had 1.57 times the risk of experiencing the death of a caregiver relative to those in very high opportunity neighborhoods (95% CI, 1.50-1.64), which remained after adjustment (hazard ratio, 1.30; 95% CI, 1.23-1.38). CONCLUSIONS: Our analyses advance understanding of the adverse consequences of inequitable neighborhood contexts for child well-being and underscore the potential importance of place-based policies for reducing disparities in child and caregiver mortality.

Addressing health inequities for children in immigrant families: Psychologists as leaders and links across systems.

What can psychologists do to address social determinants of health and promote health equity among America's approximately 20 million children in immigrant families (CIF)? This article identifies gaps in current research and argues for a stronger role for psychologists. Psychologists can advocate for and enact changes in institutional systems that contribute to inequities in social determinants of health and promote resources and services necessary for CIF to flourish. We consider systemic exclusionary and discriminatory barriers faced by CIF, including a heightened anti-immigrant political climate, continued threat of immigration enforcement, restricted access to the social safety net, and the disproportionate health, economic, and educational burden of the COVID-19 pandemic. We highlight the potential role of psychologists in (a) leading prevention that addresses stressors such as poverty and trauma; (b) changing systems to mitigate risk factors for CIF; (c) expanding workforce development across multiple disciplines to better serve their needs; (d) identifying mechanisms, such as racial profiling, that contribute to health inequity, and viewing them as public health harms; and (e) guiding advocacy for resources at local, state, and federal levels, including by linking discriminatory policies or practices with health inequity. A key recommendation to increase psychologists' impact is for academic and professional institutions to strengthen relationships with policymakers to effectively convey these findings in spaces where decisions about policies and practices are made. We conclude that psychologists are well positioned to promote systemic change across multiple societal levels and disciplines to improve the well-being of CIF and offer them a better future. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course.

Preterm birth is associated with an increased risk of neurodevelopmental and neurobehavioral impairments including attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood. In this narrative review, we examine the known associations between prematurity and ADHD and highlight the impact of both prematurity and ADHD on multiple domains across the pediatric life-course. We develop a framework for understanding the health services journey of individuals with ADHD to access appropriate services and treatments for ADHD, the "ADHD Care Cascade". We then discuss the many racial and ethnic inequities that affect the risk of preterm birth as well as the steps along the "ADHD Care Cascade". By using a life-course approach, we highlight the ways in which inequities are layered over time to magnify the neurodevelopmental impact of preterm birth on the most vulnerable children across the life-course.

Connecting past to present: Examining different approaches to linking historical redlining to present day health inequities.

In the 1930's, the Home Owner Loan Corporation (HOLC) drafted maps to quantify variation in real estate credit risk across US city neighborhoods. The letter grades and associated risk ratings assigned to neighborhoods discriminated against those with black, lower class, or immigrant residents and benefitted affluent white neighborhoods. An emerging literature has begun linking current individual and community health effects to government redlining, but each study faces the same measurement problem: HOLC graded area boundaries and neighborhood boundaries in present-day health datasets do not match. Previous studies have taken different approaches to classify present day neighborhoods (census tracts) in terms of historical HOLC grades. This study reviews these approaches, examines empirically how different classifications fare in terms of predictive validity, and derives a predictively optimal present-day neighborhood redlining classification for neighborhood and health research.

Family Stressors and Resources as Social Determinants of Health among Caregivers and Young Children.

Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers' depressive symptoms, anxiety symptoms, and sleep problems, and young children's medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers' depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children's health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being.

Are building-level characteristics associated with indoor allergens in the household?

Building-level characteristics are structural factors largely beyond the control of those who live in them. We explored whether building-level characteristics and indoor allergens in the household are related. We examined the relationship between building-level characteristics and indoor allergens: dust mite, cat, cockroach, and mouse. Building-level characteristics measured were presence of pests (seeing cockroaches and rodents), building type (public housing, buildings zoned commercially and residentially, and building size), and building condition (building age and violations). Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 µg/g; cat: >1 µg/g; cockroach: >1 U/g; mouse: >1.6 µg/g. In fully adjusted linear analyses, neither dust mite nor cat allergen were statistically significantly associated with any building-level characteristics. Cockroach allergen was associated with the presence of cockroaches (2.07; 95% CI, 1.23, 3.49) and living in public housing (2.14; 95% CI, 1.07, 4.31). Mouse allergen was associated with the presence of rodents (1.70; 95% CI, 1.29, 2.23), and building size: living in a low-rise (<8 floors; 0.60; 95% CI, 0.42, 0.87) or high-rise (8 + floors; 0.50; 95% CI, 0.29, 0.88; compared with house/duplex). In fully adjusted logistic analyses, cat allergen was statistically significantly associated with living in a high-rise (6.29; 95% CI, 1.51, 26.21; compared with a house/duplex). Mouse allergen was associated with living in public housing (6.20; 95% CI, 1.01, 37.95) and building size: living in a low-rise (0.16; 95% CI, 0.05, 0.52) or high-rise (0.06; 95% CI, 0.01, 0.50; compared with a house/duplex). Issues concerning building size and public housing may be particularly critical factors in reducing asthma morbidity. We suggest that future research explore the possible improvement of these factors through changes to building code and violations adherence, design standards, and incentives for landlords.

Restoring An Inclusionary Safety Net For Children In Immigrant Families: A Review Of Three Social Policies.

Since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act, known as "welfare reform," in 1996, US social policy has increasingly stratified immigrants by legality, extending eligibility exclusions, benefit limitations, and administrative burdens not only to undocumented immigrants but also to lawful permanent residents and US citizens in immigrant families. This stratification is a form of structural discrimination, which is a social determinant of health. Children in immigrant families, most of whom are US citizens, have not been able to fully realize the benefits from social safety-net programs-including the 2020 Coronavirus Aid, Relief, and Economic Security Act stimulus payments. Policy deliberations over pandemic recovery, the equity focus of the Biden administration, and proposals to address child poverty provide an opportunity to reexamine immigrant exclusions, restrictions, and administrative burdens in public programs. We discuss immigrant stratification by legal status in social policy and review how it affects citizen children in mixed-status families in three safety-net programs: the Earned Income Tax Credit, Supplemental Nutrition Assistance Program, and Child Care and Development Block Grant. We provide eight policy recommendations to restore equity to the social safety net for children in immigrant families.

Including Children in Immigrant Families in Policy Approaches to Reduce Child Poverty.

Although they are an increasing share of the US child population (26% in 2020) and have much higher poverty rates than children in nonimmigrant families (20.9% vs 9.9%), children in immigrant families have much more restricted access to the social safety net, which can lead to increased economic hardship and health and developmental risks. More than 90% of children in immigrant families are US citizens, but they are excluded from the safety net due to restrictions that affect their parents and other family members. Exclusions that affect children in immigrant families include restricted categorical eligibility based on immigrant status, stricter income eligibility, reduced benefit levels, high administrative burden, and interactions with immigration policy such as public charge. These exclusions limit the ability of both existing and enhanced social programs to reduce child poverty among this population. Results derived from the Transfer Income Model simulations for the National Academy of Sciences, Engineering and Medicine's 2019 report A Roadmap to Reducing Child Poverty show that the poverty-reducing effects of potential enhancements to three main antipoverty programs result in unequal poverty reduction effects by family citizenship/immigration status with disproportionate negative effects on Hispanic children, 54% of whom live in immigrant families. Policy principles to improve equitable access and poverty-reduction effects of social programs for children in immigrant families include basing eligibility and benefit levels on the developmental, health and nutrition needs of the child instead of the immigration status of other family members, reducing administrative burden, and eliminating the link between immigration policy and access to the safety net.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes.

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Support for smoke-free policies: a nationwide analysis of immigrants, US-born, and other demographic groups, 1995-2002.

OBJECTIVES: We examined whether support for tobacco control policies varies by demographic group, including nativity status (i.e., immigrant versus US born). METHODS: We analyzed 1995 to 2002 data from the Current Population Survey Tobacco Use Supplement (n=543,951). The outcome was a summary attitudinal measure assessing support of smoking bans in 4 of 6 venues. RESULTS: US-born respondents, smokers, male respondents, Native Americans, Whites, and those who were unmarried, of lower socioeconomic status, and whose workplaces and homes were not smoke free were less likely to support smoking bans. Immigrants exhibited stronger support for banning smoking in every venue, with a generation-specific gradient in which support eroded with increasing assimilation to the United States. Levels of support were more than twice as high among immigrants as among US-born respondents (odds ratio [OR]=2.16; 95% confidence interval [CI]=2.08, 2.23). Naturalized citizens displayed higher support than US-born citizens, which may be relevant for mobilization of the electorate. Differences in population composition and contexts (e.g., smoke-free workplaces) only partially accounted for immigrants' stronger level of support. CONCLUSIONS: Immigrants and their children may be valuable tobacco control allies given their supportive attitudes toward smoke-free policies.

Are neighborhood-level characteristics associated with indoor allergens in the household?

BACKGROUND: Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning. OBJECTIVE: We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household. METHODS: Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 microg/g; cat: >1 microg/g; cockroach: >1 U/g; mouse: >1.6 microg/g. RESULTS: Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78). CONCLUSIONS: Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.

Intimate partner violence perpetration, immigration status, and disparities in a community health center-based sample of men.

OBJECTIVE: We examined disparities in male perpetration of intimate partner violence (IPV) based on immigration status. METHODS: From 2005 to 2006, 1,668 men aged 18-35 who were recruited from community health centers anonymously completed an automated, computer-assisted self-interview. Men self-reported their immigrant status (e.g., native-born, <6 years in the U.S. [recent immigrants], or > or = 6 years in the U.S. [non-recent immigrants]) and IPV perpetration. We calculated differences in IPV perpetration based on immigrant status. Among immigrant men, we further examined differences in IPV perpetration based on English-speaking ability. RESULTS: Recent immigrants were less likely to report IPV perpetration than native-born men in the overall sample (adjusted odds ratio [AOR] = 0.60, 95% confidence interval [CI] 0.36, 1.00). However, we observed no differences in IPV perpetration between non-recent immigrants and native-born men (AOR=0.88, 95% CI 0.63, 1.23). Among immigrant men, those who were non-recent immigrants and reported limited English-speaking ability were at the highest risk for IPV perpetration, compared with recent immigrants with high English-speaking ability (AOR=7.48, 95% CI 1.92, 29.08). CONCLUSIONS: Although immigrant men were at a lower risk as a group for IPV perpetration as compared with non-immigrants, this lower likelihood of IPV perpetration was only evident among recent immigrants. Among immigrant men, those who arrived in the U.S. more than six years ago and reported speaking English relatively poorly appeared to be at greatest risk for using violence against partners. Future research should examine the effects of fear of legal sanctions, discrimination, and changes in gender roles to clarify the present findings.

Housing interventions at the neighborhood level and health: a review of the evidence.

A panel of subject matter experts systematically reviewed evidence linking neighborhood-level housing interventions, such as housing programs or policies, to health outcomes. One of the 10 interventions reviewed--the Housing Choice Voucher Program--had sufficient evidence for implementation or expansion. The evidence showed that voucher holders are less likely to suffer from overcrowding, malnutrition due to food insecurity, and concentrated neighborhood poverty than non-voucher holders. Of the other reviewed interventions, 2 needed more field evaluation and 7 needed more formative research. None were determined to be ineffective. Although many of the reviewed interventions lacked sufficient evidence for widespread implementation solely based on their health benefits, this evidence review shows that many interventions positively affect other areas of social, economic, and environmental well-being. Efforts to improve neighborhood environments and to maintain and increase the number of affordable housing units are critical to ensuring safe, healthy, and affordable housing for all people in the United States. Given that people of color disproportionately reside in high-poverty neighborhoods, neighborhood-level interventions may be particularly important in efforts to eliminate health disparities.

Racial And Ethnic Inequities In Children's Neighborhoods: Evidence From The New Child Opportunity Index 2.0.

Neighborhoods influence children's health, so it is important to have measures of children's neighborhood environments. Using the Child Opportunity Index 2.0, a composite metric of the neighborhood conditions that children experience today across the US, we present new evidence of vast geographic and racial/ethnic inequities in neighborhood conditions in the 100 largest metropolitan areas in the US. Child Opportunity Scores range from 20 in Fresno, California, to 83 in Madison, Wisconsin. However, more than 90 percent of the variation in neighborhood opportunity happens within metropolitan areas. In 35 percent of these areas the Child Opportunity Gap (the difference between Child Opportunity Scores in very low- and very high-opportunity neighborhoods) is higher than across the entire national neighborhood distribution. Nationally, the Child Opportunity Score for White children (73) is much higher than for Black (24) and Hispanic (33) children. To improve children's health and well-being, the health sector must move beyond a focus on treating disease or modifying individual behavior to a broader focus on neighborhood conditions. This will require the health sector to both implement place-based interventions and collaborate with other sectors such as housing to execute mobility-based interventions.