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.

Development and Multicenter Case-Control Validation of Urinary Comprehensive Genomic Profiling for Urothelial Carcinoma Diagnosis, Surveillance, and Risk-Prediction.

PURPOSE: Urinary comprehensive genomic profiling (uCGP) uses next-generation sequencing to identify mutations associated with urothelial carcinoma and has the potential to improve patient outcomes by noninvasively diagnosing disease, predicting grade and stage, and estimating recurrence risk. EXPERIMENTAL DESIGN: This is a multicenter case-control study using banked urine specimens collected from patients undergoing initial diagnosis/hematuria workup or urothelial carcinoma surveillance. A total of 581 samples were analyzed by uCGP: 333 for disease classification and grading algorithm development, and 248 for blinded validation. uCGP testing was done using the UroAmp platform, which identifies five classes of mutation: single-nucleotide variants, copy-number variants, small insertion-deletions, copy-neutral loss of heterozygosity, and aneuploidy. UroAmp algorithms predicting urothelial carcinoma tumor presence, grade, and recurrence risk were compared with cytology, cystoscopy, and pathology. RESULTS: uCGP algorithms had a validation sensitivity/specificity of 95%/90% for initial cancer diagnosis in patients with hematuria and demonstrated a negative predictive value (NPV) of 99%. A positive diagnostic likelihood ratio (DLR) of 9.2 and a negative DLR of 0.05 demonstrate the ability to risk-stratify patients presenting with hematuria. In surveillance patients, binary urothelial carcinoma classification demonstrated an NPV of 91%. uCGP recurrence-risk prediction significantly prognosticated future recurrence (hazard ratio, 6.2), whereas clinical risk factors did not. uCGP demonstrated positive predictive value (PPV) comparable with cytology (45% vs. 42%) with much higher sensitivity (79% vs. 25%). Finally, molecular grade predictions had a PPV of 88% and a specificity of 95%. CONCLUSIONS: uCGP enables noninvasive, accurate urothelial carcinoma diagnosis and risk stratification in both hematuria and urothelial carcinoma surveillance patients.

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.

Feasibility study of a health coaching intervention to improve contraceptive continuation in adolescent and young adult women in Philadelphia, Pennsylvania.

INTRODUCTION: Few interventions to improve contraceptive continuation are tailored to meet the developmental needs of young women under age 25 years. The Health Coaching for Contraceptive Continuation (HC3) intervention was designed to address this gap. In this special report, we describe the rationale for using health coaching, conceptual framework, intervention processes, and findings from a single-arm feasibility study of the intervention protocol. METHODOLOGY: Health coaching is a person-centered behavioral change approach organized around five main strategies: providing education relevant to health goals, building health self-management skills, offering patient-centered counseling, identifying barriers to adherence, and fostering personal accountability for achieving health goals. We used these strategies to affect theory-driven mediators delineated in the Integrative Model of Behavioral Prediction (intentions, knowledge, attitudes, perceived social norms, and self-efficacy) and clinical mediators posited to change through program participation (shared contraceptive decision-making, method satisfaction, quality of life, distress tolerance, experiential avoidance, patient-coach alliance, and expectations of treatment effect). Experienced sexual health educators completed a manualized, 4-week health training program adapted from the National Society of Health Coaches. Between March and December 2017, we recruited a convenience sample of sexually-active women ages 14-21 years who initiated a new contraceptive in the prior 14 days from three urban pediatric clinics in Philadelphia, Pennsylvania. At baseline, participants completed a socio-demographic questionnaire, contraceptive needs assessment interview, and prioritized reproductive topics to learn more about. We synthesized these data into a coaching plan that guided the monthly coaching sessions which occurred for 6 months following contraceptive initiation. We assessed method adherence and continuation with monthly follow-up questionnaires and corroborated the findings through electronic medical record and pharmacy refill data review. Exit interviews assessed program acceptability. Feasibility outcomes measured throughout the protocol administration included recruitment and retention success. We used descriptive statistics to assess baseline and follow up questionnaire measures and audio-recorded and transcribed exit interviews verbatim. Two independent coders used deductive and inductive content analysis coding approaches to identify themes related to program acceptability. RESULTS: Of 92 women approached for the longitudinal intervention, 33 enrolled. Participants' mean age was 17.4 ± 2.1 years. Most were Black (n = 24), in high school (n = 23), and single/never-married (n = 31). Twenty-one completed ≥4 coaching sessions. Among the 23 for whom 6-month contraceptive continuation could be determined, 20 continued their baseline method, 2 switched methods without a gap in use, and 1 discontinued contraceptive use. Five were lost to follow up after enrollment; continuation status was indeterminant for the remaining five. Among the 22 who completed exit interviews, all expressed high program acceptability citing that it provided knowledge-based benefits, nonknowledge-based benefits, and an opportunity to develop a positive, supportive relationship with a reproductive health expert. Participants provided feedback on logistical aspects of the program they enjoyed and made suggestions for improvements prior to embarking on a larger efficacy trial. DISCUSSION: Health coaching is a new approach for promoting contraceptive continuation in young women. The conceptual framework, program structure, and feasibility findings demonstrate strong support for the program among participants. Subsequent research must explore program effects on contraceptive continuation and prevention of unintended pregnancy.