Neighborhood Disadvantage and Cumulative Biological Risk Among a Socioeconomically Diverse Sample of African American Adults: An Examination in the Jackson Heart Study.

OBJECTIVES: Neighborhoods characterized by disadvantage influence multiple risk factors for chronic disease and are considered potential drivers of racial and ethnic health inequities in the USA. The objective of the present study was to examine the relationship between neighborhood disadvantage and cumulative biological risk (CBR) and the extent to which the association differs by individual income and education among a large, socioeconomically diverse sample of African American adults. METHODS: Data from the baseline examination of the Jackson Heart Study (2000-2004) were used for the analyses. The sample consisted of African American adults ages 21-85 with complete, geocoded data on CBR biomarkers and behavioral covariates (n = 4410). Neighborhood disadvantage was measured using a composite score of socioeconomic indicators from the 2000 US Census. Eight biomarkers representing cardiovascular, metabolic, inflammatory, and neuroendocrine systems were used to create a CBR score. We fit two-level linear regression models with random intercepts and included cross-level interaction terms between neighborhood disadvantage and individual socioeconomic status (SES). RESULTS: Living in a disadvantaged neighborhood was associated with greater CBR after covariate adjustment (B = 0.18, standard error (SE) 0.07, p < 0.05). Interactions showed a weaker association for individuals with ≤high school education but were not statistically significant. CONCLUSION: Disadvantaged neighborhoods contribute to poor health among African American adults via cumulative biological risk. Policies directly addressing the socioeconomic conditions of these environments should be considered as viable options to reduce disease risk in this group and mitigate racial/ethnic health inequities.

Double-jeopardy: The joint impact of neighborhood disadvantage and low social cohesion on cumulative risk of disease among African American men and women in the Jackson Heart Study.

OBJECTIVES: Few studies have examined the joint impact of neighborhood disadvantage and low social cohesion on health. Moreover, no study has considered the joint impact of these factors on a cumulative disease risk profile among a large sample of African American adults. Using data from the Jackson Heart Study, we examined the extent to which social cohesion modifies the relationship between neighborhood disadvantage and cumulative biological risk (CBR)-a measure of accumulated risk across multiple physiological systems. METHODS: Our analysis included 4408 African American women and men ages 21-85 residing in the Jackson, MS Metropolitan Area. We measured neighborhood disadvantage using a composite score of socioeconomic indicators from the 2000 US Census and social cohesion was assessed using a 5-item validated scale. Standardized z-scores of biomarkers representing cardiovascular, metabolic, inflammatory, and neuroendocrine systems were combined to create a CBR score. We used two-level linear regression models with random intercepts adjusting for socio-demographic and behavioral covariates in the analysis. A three-way interaction term was included to examine whether the relationship between neighborhood disadvantage and CBR differed by levels of social cohesion and gender. RESULTS: The interaction between neighborhood disadvantage, social cohesion and gender was statistically significant (p = 0.05) such that the association between living in a disadvantaged neighborhood and CBR was strongest for men living in neighborhoods with low levels of social cohesion (B = 0.63, SE: 0.32). In gender-specific models, we found a statistically significant interaction between neighborhood disadvantage and social cohesion for men (p = 0.05) but not for women (p = 0.50). CONCLUSION: Neighborhoods characterized by high levels of economic disadvantage and low levels of social cohesion contribute to higher cumulative risk of disease among African American men. This suggests that they may face a unique set of challenges that put them at greater risk in these settings.

All black people are not alike: differences in HIV testing patterns, knowledge, and experience of stigma between U.S.-born and non-U.S.-born blacks in Massachusetts.

Non-U.S.-born black individuals comprise a significant proportion of the new diagnoses of HIV in the United States. Concurrent diagnosis (obtaining an AIDS diagnosis in close proximity to an initial diagnosis of HIV) is common in this subpopulation. Although efforts have been undertaken to increase HIV testing among African Americans, little is known about testing patterns among non-U.S.-born black people. A cross-sectional survey was self-administered by 1060 black individuals in Massachusetts (57% non-U.S.-born) to assess self-reported rates of HIV testing, risk factors, and potential barriers to testing, including stigma, knowledge, immigration status, and access to health care. Bivariate analysis comparing responses by birthplace and multivariate logistic regression assessing correlates of recent testing were completed. Non-U.S.-born individuals were less likely to report recent testing than U.S.-born (41.9% versus 55.6%, p<0.0001). Of those who recently tested, the majority did so for immigration purposes, not because of perceived risk. Stigma was significantly higher and knowledge lower among non-U.S.-born individuals. In multivariate analysis, greater length of time since immigration was a significant predictor of nontesting among non-U.S.-born (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.36-0.87). Poor health care access and older age were correlated to nontesting in both U.S.- and non-U.S.-born individuals. Our findings indicate that differences in HIV testing patterns exist by nativity. Efforts addressing unique factors limiting testing in non-U.S.-born black individuals are warranted.

Differential mental health effects of neighborhood relocation among youth in vulnerable families: results from a randomized trial.

CONTEXT Extensive observational evidence indicates that youth in high-poverty neighborhoods exhibit poor mental health, although not all children may be affected similarly. OBJECTIVE To use experimental evidence to assess whether gender and family health problems modify the mental health effects of moving from high- to low-poverty neighborhoods. DESIGN Randomized controlled trial. SETTING Volunteer low-income families in public housing in 5 US cities between 1994-1997. PARTICIPANTS We analyze 4- to 7-year outcomes in youth aged 12 to 19 years (n = 2829, 89% effective response rate) in the Moving to Opportunity Study. INTERVENTION Families were randomized to remain in public housing (control group) or to receive government-funded rental subsidies to move into private apartments (experimental group). Intention-to-treat analyses included intervention interactions by gender and health vulnerability (defined as prerandomization health/developmental limitations or disabilities in family members). MAIN OUTCOME MEASURES Past-year psychological distress (Kessler 6 scale [K6]) and the Behavioral Problems Index (BPI). Supplemental analyses used past-year major depressive disorder (MDD). RESULTS Male gender (P = .02) and family health vulnerability (P = .002) significantly adversely modified the intervention effect on K6 scores; male gender (P = .01), but not health vulnerability (P = .17), significantly adversely modified the intervention effect on the BPI. Girls without baseline health vulnerabilities were the only subgroup to benefit on any outcome (K6: ß = -0.21; 95% CI, -0.34 to -0.07; P = .003; MDD: odds ratio = 0.42; 95% CI, 0.20 to 0.85; P = .02). For boys with health vulnerabilities, intervention was associated with worse K6 (ß = 0.26; 95% CI, 0.09 to 0.44; P = .003) and BPI (ß = 0.24; 95% CI, 0.09 to 0.40; P = .002) values. Neither girls with health vulnerability nor boys without health vulnerability experienced intervention benefits. Adherence-adjusted instrumental variable analysis found intervention effects twice as large. Patterns were similar for MDD, but estimates were imprecise owing to low prevalence. CONCLUSIONS Although some girls benefited, boys and adolescents from families with baseline health problems did not experience mental health benefits from housing mobility policies and may need additional program supports.

Gender and crime victimization modify neighborhood effects on adolescent mental health.

OBJECTIVE: Leverage an experimental study to determine whether gender or recent crime victimization modify the mental health effects of moving to low-poverty neighborhoods. METHODS: The Moving to Opportunity (MTO) study randomized low-income families in public housing to an intervention arm receiving vouchers to subsidize rental housing in lower-poverty neighborhoods or to controls receiving no voucher. We examined 3 outcomes 4 to 7 years after randomization, among youth aged 5 to 16 years at baseline (n = 2829): lifetime major depressive disorder (MDD), psychological distress (K6), and Behavior Problems Index (BPI). Treatment effect modification by gender and family's baseline report of recent violent crime victimization was tested via interactions in covariate-adjusted intent-to-treat and instrumental variable adherence-adjusted regression models. RESULTS: Gender and crime victimization significantly modified treatment effects on distress and BPI (P < .10). Female adolescents in families without crime victimization benefited from MTO treatment, for all outcomes (Distress B = -0.19, P = .008; BPI B = -0.13, P = .06; MDD B = -0.036, P = .03). Male adolescents in intervention families experiencing crime victimization had worse distress (B = 0.24, P = .004), more behavior problems (B = 0.30, P < .001), and nonsignificantly higher MDD (B = 0.022, P = .16) versus controls. Other subgroups experienced no effect of MTO treatment. Instrumental variable estimates were similar but larger. CONCLUSIONS: Girls from families experiencing recent violent crime victimization were significantly less likely to achieve mental health benefits, and boys were harmed, by MTO, suggesting need for cross-sectoral program supports to offset multiple stressors.

Enhancing adolescent self-efficacy and collective efficacy through public engagement around HIV/AIDS competence: a multilevel, cluster randomized-controlled trial.

The potential capacity of children to confront the HIV/AIDS pandemic is rarely considered. Interventions to address the impact of the pandemic on children and adolescents commonly target only their vulnerabilities. We evaluated the Young Citizens Program, an adolescent-centered health promotion curriculum designed to increase self- and collective efficacy through public education and community mobilization across a municipality in the Kilimanjaro Region of Tanzania. The theoretical framework for the program integrates aspects of human capability, communicative action, social ecology and social cognition. The design consists of a cluster randomized-controlled trial (CRCT). Fifteen pairs of matched geopolitically defined neighborhoods of roughly 2000-4000 residents were randomly allocated to treatment and control arms. Within each neighborhood cluster, 24 randomly selected adolescents, ages 9-14, deliberated on topics of social ecology, citizenship, community health and HIV/AIDS competence. Building on their acquired understanding and confidence, they dramatized the scientific basis and social context of HIV infection, testing and treatment in their communities over a 28-week period. The curriculum comprised 5 modules: Group Formation, Understanding our Community, Health and our Community, Making Assessments and Taking Action in our Community and Inter-Acting in our Community. Adolescent participants and adult residents representative of their neighborhoods were surveyed before and after the intervention; data were analyzed using multilevel modeling. In treatment neighborhoods, adolescents increased their deliberative and communicative efficacy and adults showed higher collective efficacy for children. Following the CRCT assessments, the control group received the same curriculum. In the Kilimanjaro Region, the Young Citizens Program is becoming recognized as a structural, health promotion approach through which adolescent self-efficacy and child collective efficacy are generated in the context of civil society and local government.

Connectedness, social support and internalising emotional and behavioural problems in adolescents displaced by the Chechen conflict.

The study investigated factors associated with internalising emotional and behavioural problems among adolescents displaced during the most recent Chechen conflict. A cross-sectional survey (N=183) examined relationships between social support and connectedness with family, peers and community in relation to internalising problems. Levels of internalising were higher in displaced Chechen youth compared to published norms among non-referred youth in the United States and among Russian children not affected by conflict. Girls demonstrated higher problem scores compared to boys. Significant inverse correlations were observed between family, peer and community connectedness and internalising problems. In multivariate analyses, family connectedness was indicated as a significant predictor of internalising problems, independent of age, gender, housing status and other forms of support evaluated. Sub-analyses by gender indicated stronger protective relationships between family connectedness and internalising problems in boys. Results indicate that family connectedness is an important protective factor requiring further exploration by gender in war-affected adolescents.

Prenatal cigarette exposure and infant learning stimulation as predictors of cognitive control in childhood.

Prenatal exposures to neurotoxins and postnatal parenting practices have been shown to independently predict variations in the cognitive development and emotional-behavioral well-being of infants and children. We examined the independent contributions of prenatal cigarette exposure and infant learning stimulation, as well as their inter-relationships in predicting variations in the proficiency of executive attention, a core element of cognitive control and self-regulation. Participants were an ethnic-racially, socio-economically diverse sample of 249 children followed from birth in the Project on Human Development in Chicago Neighborhoods. We obtained histories of prenatal exposure to alcohol, cigarettes, and other drugs, and we assessed socio-economic status and learning stimulation during a home visit when the participants were infants. In childhood we utilized the Attention Networks Test to assess the proficiency of executive attention during two home visits, one year apart. Accounting for age, SES, prenatal alcohol exposure, and baseline performance, we found that prenatal cigarette exposure impaired the speed of executive attention. Infant learning stimulation mitigated these effects, and predicted better accuracy of executive attention as well, suggestive of both protective and health promoting effects. Effect sizes for these relations, whether examined independently or by their inter-relationships, were comparable to if not greater in magnitude than the effects of age on speed and accuracy, highlighting the importance of these very early experiences in shaping the proficiency of self-regulation. Since executive attention is central to cognitive control and self-regulation, previously described relations between prenatal cigarette exposure, parenting practices, and some forms of childhood psychopathology may be contingent on how early learning stimulation contributes to the proficiency of executive attention through direct and indirect effects. Furthermore, considering the prolonged developmental trajectory of executive attention, interventions to support provision of learning stimulation may mitigate poor outcomes for some at-risk children by promoting development of more proficient executive attention.

Darwin and Lincoln: their legacy of human dignity.

The legacy of Charles Darwin and Abraham Lincoln is to champion the dignity inherent in every human being. The moment of the bicentennial of their births provides an opportunity to celebrate and reflect on ways they have shaped our understanding and commitment to human rights. The naturalist and the constitutional lawyer, so different in circumstance and discipline, were morally allied in the mission to eradicate slavery. The profound lessons to be extracted from the lives of these two icons bind us to the agonizing reality that nearly 150 years after Gettysburg and the publication of the Descent of Man, and Selection in Relation to Sex, there remains much work to do toward advancing the security, respect, and equality of our species. This article describes how Darwin and Lincoln's inspiring legacies guided the author's personal choices as a scientist and activist. The essay concludes with a set of questions and challenges that confront us, foremost among which is the need to balance actions in response to the violation of negative rights by actions in the pursuit of positive rights.

Socioeconomic status and HIV seroprevalence in Tanzania: a counterintuitive relationship.

OBJECTIVE: To examine the relationship between multiple dimensions of socioeconomic status (SES) and HIV seroprevalence in Tanzania. METHODS: Using a large nationally representative sample of 7515 sexually active adults drawn from the 2003-04 Tanzania HIV/AIDS Indicator Survey, we analysed the relationship between multiple SES measures and HIV seroprevalence using weighted logistic regression models. RESULTS: In adjusted models, individuals in the highest quintile of standard of living had increased odds ratio (OR) of being HIV-positive (male: OR 2.38, 95% CI 1.17-4.82; female: OR 3.74, 95% CI 2.16-6.49). Occupational status was differentially associated with HIV in men and women; women in professional jobs had higher OR of being HIV-positive (OR 1.54, 95% CI 1.02-2.38), whereas unemployed men had higher risk of being HIV-positive (OR 3.49, 95% CI 1.43-8.58). No marked association was found between increasing education and HIV seroprevalence for men (P = 0.83) and women (P = 0.87). CONCLUSION: Contrary to the prevailing perception that low SES individuals tend to be more vulnerable to HIV-infection, we found a positive association between standard of living and HIV-infection. Strategies aimed at reducing HIV-infection needs to be cognizant of the complex social heterogeneity in the patterns of HIV-infection.

Place matters: multilevel investigation of HIV distribution in Tanzania.

OBJECTIVE: To examine the extent to which the regional and neighborhood distribution of HIV in Tanzania is caused by the differential distribution of individual correlates and risk factors. METHODS: Nationally representative, cross-sectional data on 12,522 women and men aged 15-49 years from the 2003-2004 Tanzanian AIDS Indicator Survey. Three-level multilevel binary logistic regression models were specified to estimate the relative contribution of regions and neighborhoods to the variation in HIV seroprevalence. RESULTS: Spatial distribution of individual correlates (and risk factors) of HIV do not explain the neighborhood and regional variation in HIV seroprevalence. Neighborhoods and regions accounted for approximately 14 and 6% of the total variation in HIV. HIV prevalence ranged from 1.8% (Kigoma) to 6.7% (Iringa) even after adjusting for the compositional make-up of these regions. An inverse association was observed between log odds of being HIV positive and neighborhood poverty [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.09-0.61] and regional poverty (OR 0.97, 95% CI 0.95-0.99). CONCLUSION: Our study provides evidence for independent contextual variations in HIV, above and beyond that which can be ascribed to geographical variations in individual-level correlates and risk factors. We emphasize the need to adopt both a group-based and a place-based approach, as opposed to the dominant high-risk group approach, for understanding the epidemiology of HIV as well as for developing HIV intervention activities.

Promoting child and adolescent mental health in the context of the HIV/AIDS pandemic with a focus on sub-Saharan Africa.

BACKGROUND: The pandemic of HIV/AIDS is actually a composite of many regional and national-level epidemics. The progress made in many parts of the developed and developing world is tempered by the continued devastating consequences of HIV infection in sub-Saharan Africa (SSA). This review focuses on the ways in which children and adolescents are impacted by the epidemic, giving particular attention to their mental health. METHODS: A health promotion framework is adopted to guide analysis. Three issues are covered: prevention of HIV infection, care and treatment of children infected with HIV, and care of children whose caregivers are ill or have died of AIDS. Existing reviews and literature search engines were used to review the scientific literature, focusing on the past five years. RESULTS: Preventive interventions continue to manifest limited benefits in behavioral changes. More complex causal models and improved behavioral measures are needed. In the African context, the time has come to view pediatric AIDS as a chronic disease in which the mental health of caregivers and children influences important aspects of disease prevention and management. Increasingly sophisticated studies support earlier findings that social and psychological functioning, educational achievement and economic well-being of children who lose parents to AIDS are worse than that of other children. CONCLUSIONS: Important changes are taking place in SSA in increased access to HIV testing and antiretroviral therapies. To be effective in promoting mental health of children and adolescents, interventions require a more fundamental understanding of how to build HIV competence at personal and community levels. A key recommendation calls for the design and execution of population-based studies that include both multilevel and longitudinal features. Such rigorous conceptual and empirical investigations that assess the capacities of children are required to mobilize children, families and communities in comprehensive actions plans for prevention, treatment and care in response to the enduring HIV/AIDS pandemic.

Young citizens as health agents: use of drama in promoting community efficacy for HIV/AIDS.

A community-based cluster randomized control trial in a medium-sized municipality in Tanzania was designed to increase local competence to control HIV/AIDS through actions initiated by children and adolescents aged 10 to 14 years. Representative groups from the 15 treatment communities reached mutual understanding about their objectives as health agents, prioritized their actions, and skillfully applied community drama ("skits") to impart knowledge about the social realities and the microbiology of HIV/AIDS. In independently conducted surveys of neighborhood residents, differences were found between adults who did and did not witness the skits in their beliefs about the efficacy of children as HIV/AIDS primary change agents.

Firearm violence exposure and serious violent behavior.

To estimate the cause-effect relationship between exposure to firearm violence and subsequent perpetration of serious violence, we applied the analytic method of propensity stratification to longitudinal data on adolescents residing in Chicago, Illinois. Results indicate that exposure to firearm violence approximately doubles the probability that an adolescent will perpetrate serious violence over the subsequent 2 years.

Neighborhood residence and mental health problems of 5- to 11-year-olds.

CONTEXT: Little research has investigated possible effects of neighborhood residence on mental health problems in children such as depression, anxiety, and withdrawal. OBJECTIVE: To examine whether children's mental health is associated with neighborhood structural characteristics (concentrated disadvantage, immigrant concentration, and residential stability) and whether neighborhood social processes (collective efficacy and organizational participation) underlie such effects. DESIGN AND SETTING: The Project on Human Development in Chicago Neighborhoods is a multilevel, longitudinal study of a representative sample of children aged 5 to 11 years in the late 1990s recruited from 80 neighborhoods. A community survey assessing neighborhood social processes was conducted with an independent sample of adult residents in these 80 neighborhoods and is used in conjunction with US census data to assess neighborhood conditions. PARTICIPANTS: A total of 2805 children (18.1% European American, 33.8% African American, and 48.1% Latino) and their primary caregivers were seen twice. MAIN OUTCOME MEASURES: Child Behavior Checklist total raw and clinical cutoff scores for internalizing behavior problems (depression, anxiety, withdrawal, and somatic problems). RESULTS: The percentages of children above the clinical threshold were 21.5%, 18.3%, and 11.5% in neighborhoods of low, medium, and high socioeconomic status, respectively. A substantial proportion of variance in children's total internalizing scores (intraclass correlation, 11.1%) was attributable to between-neighborhood differences. Concentrated disadvantage was associated with more mental health problems and a higher number of children in the clinical range, after accounting for family demographic characteristics, maternal depression, and earlier child mental health scores. Neighborhood collective efficacy and organizational participation were associated with better mental health, after accounting for neighborhood concentrated disadvantage. Collective efficacy mediated the effect of concentrated disadvantage. CONCLUSIONS: A large number of children in poor neighborhoods have mental health problems. The mechanism through which neighborhood economic effects operated was community social control and cohesion, which may be amenable to intervention.

Behavioral profiles in 4-5 year-old children: normal and pathological variants.

Normal and psychopathological patterns of behavior symptoms in pre-school children were described by a classification approach using cluster analysis. The behavior of 406 children, average age 4 years 9 months, from the general population was evaluated at home visits. Seven clusters were identified based on empirically defined dimensions: attention, hyperactivity, aggressiveness, social relationship problems, sleeping problems, eating problems, depression and anxiety. Clusters scoring high in inattention, hyperactivity, aggressiveness, and social relationship problems but low in depression and anxiety were found and could indicate early onset conduct disorder. The approach of analysing patterns of symptoms expands the basis on which normal and psychopathological patterns are distinguished.

Links between pubertal timing and neighborhood contexts: implications for girls' violent behavior.

OBJECTIVE: To investigate links between girls' violent behavior, pubertal timing, and neighborhood characteristics. METHOD: A total of 501 Hispanic, black, and white adolescent girls and their parents were interviewed twice over a 3-year period (1995-1998). Violent behavior was assessed using the Self-Report of Offending Scale and pubertal timing was measured via menarche. This probability sample was drawn from Chicago. To characterize neighborhoods, neighborhood clusters were created. U.S. Census data were mapped onto each neighborhood cluster to represent levels of concentrated disadvantage, immigrant concentration, and residential mobility. The response rate was approximately 70%. RESULTS: More than 25% of girls engaged in violent behavior at the second interview. Controlling for demographic indicators, previous violence, and other psychological factors, no differences were found in violent behavior as a function of menarcheal timing or neighborhood characteristics. Instead, results revealed that early maturers engaged in violent behavior only if they lived in neighborhoods characterized by high concentrated disadvantage. Early maturers in neighborhoods characterized by high concentrated disadvantaged engaged in three times the number of violent acts as early maturers in less disadvantaged neighborhoods. Depressive symptoms and previous violent behavior were also associated with girls' subsequent violent behavior. CONCLUSIONS: Results indicated that girls who experience a double vulnerability--early maturation and neighborhoods of disadvantage--are susceptible to engaging in violent behavior. This suggests the need for clinical evaluation to examine the implications of pubertal timing and the context of girls' behavior.