Is gastroschisis associated with county-level socio-environmental quality during pregnancy?

BACKGROUND: Gastroschisis prevalence more than doubled between 1995 and 2012. While there are individual-level risk factors (e.g., young maternal age, low body mass index), the impact of environmental exposures is not well understood. METHODS: We used the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) as a county-level estimate of cumulative environmental exposures for five domains (air, water, land, sociodemographic, and built) and overall from 2006 to 2010. Adjusted odds ratios (aOR) and 95% confidence interval (CI) were estimated from logistic regression models between EQI tertiles (better environmental quality (reference); mid; poorer) and gastroschisis in the National Birth Defects Prevention Study from births delivered between 2006 and 2011. Our analysis included 594 cases with gastroschisis and 4105 infants without a birth defect (controls). RESULTS: Overall EQI was modestly associated with gastroschisis (aOR [95% CI]: 1.29 [0.98, 1.71]) for maternal residence in counties with poorer environmental quality, compared to the reference (better environmental quality). Within domain-specific indices, only the sociodemographic domain (aOR: 1.51 [0.99, 2.29]) was modestly associated with gastroschisis, when comparing poorer to better environmental quality. CONCLUSIONS: Future work could elucidate pathway(s) by which components of the sociodemographic domain or possibly related psychosocial factors like chronic stress potentially contribute to risk of gastroschisis.

Feasibility of Using Rideshare Transportation to Reduce Barriers to Participating in a Clinic-based Food Insecurity Intervention.

BACKGROUND: Few clinic-based food insecurity interventions address transportation barriers to utilizing food resources. OBJECTIVES: We assessed the feasibility of using free rideshare-based transportation to reduce barriers to participating in an ongoing clinic-based food insecurity intervention. METHODS: Our multi-methods pilot study used patient surveys (n = 155), focus groups with clinic and program staff (n = 10), and rideshare usage data. RESULTS: Of the 95 (61.2%) survey respondents who reported transportation barriers, only 34 (21.9%) used rideshare. More than 80% of rideshare users rated their experience as good or excellent. Clinic and program staff reported that the service allowed patients a greater sense of control over their time and health and emphasized the need for staffing and program-level infrastructure. CONCLUSIONS: Free rideshare may address transportation barriers for some patients but multiple options for support and adjustments to how we offer transportation solutions are needed to successfully meet the needs of all program participants experiencing transportation barriers.

Prenatal exposure to perceived stress, maternal asthma, and placental size.

INTRODUCTION: Prenatal exposure to stress has been associated with poor pregnancy outcomes, yet evidence linking stress and placental size is limited. Asthma is associated with worse pregnancy outcomes and women with asthma may be more susceptible to stress. Using the asthma-enriched B-WELL-Mom cohort, we examined the association between perceived stress and placental size. METHODS: Placental measures of weight, length, width, and thickness were available for 345 women (262 with asthma) via placental pathology report. Perceived Stress Scale (PSS) scores were obtained in each trimester of pregnancy and categorized into quartiles (low quartile as reference). For associations between PSS and placental size, generalized estimating equations adjusted for maternal and infant factors were used to estimate regression coefficients (ß) and 95% confidence intervals (95% CI). Full models and models stratified by asthma status were run. RESULTS: Compared to Quartile 1, high levels of stress (Quartile 4) were associated with smaller placental weight (-20.63 95% CI: -37.01,-4.26) and length (-0.55 95% CI: -0.96,-0.15), but not width or thickness. Results by asthma status show a stronger association between perceived stress and shorter placental length in those with asthma and a stronger association between perceived stress and smaller placental thickness in those without asthma. Findings were robust to sensitivity analyses DISCUSSION: Higher levels of perceived stress were associated with smaller placental size. Additional research is warranted to understand the relationship between stress and placental size.

Characteristics associated with downward residential mobility among birthing persons in California.

BACKGROUND: Substantial research documents health consequences of neighborhood disadvantage. Patterns of residential mobility that differ by race/ethnicity and socioeconomic status (SES) may sort non-Hispanic (NH) Black and low-SES families into disadvantaged neighborhoods. In this study, we leverage a sibling-linked dataset to track residential mobility among birthing persons between pregnancies and investigate baseline characteristics associated with downward mobility, including race/ethnicity, SES, and pre-existing health conditions. METHODS: We used a probabilistic linkage strategy to identify births to the same person between 2007 and 2015 (n = 624,222) and categorized downward residential mobility by quartile-level increases in neighborhood disadvantage. We defined strong downward mobility as a move from a neighborhood with very low (quartile 1) to very high (quartile 4) disadvantage and estimated the logit (i.e., log-odds) of strong downward mobility as a function of racial/ethnic, sociodemographic, and health characteristics of the birthing person and their first birth. We further explored the role of neighborhood housing affordability by examining changes in affordability from first to second birth by race/ethnicity. RESULTS: NH Black birthing persons show an over three-fold increased odds of strong downward mobility relative to NH white birthing persons (OR = 3.34, CI: 2.91, 3.84). To a lesser extent, Hispanic race/ethnicity, WIC receipt, low educational attainment, obesity, and infant preterm birth (PTB) also predict strong downward mobility. Examination of changes in neighborhood affordability indicate that over half of NH Black birthing persons move to a more affordable neighborhood, compared to less than a quarter of NH white birthing persons, before the birth of their second child. Results remain consistent across outcomes, measures of neighborhood SES, and modified log-Poisson models. CONCLUSION: We find an elevated risk of strong downward mobility among NH Black and low-SES birthing persons. Future research may identify other factors (e.g., housing affordability) that generate downward residential mobility to identify interventions that promote neighborhood equity.

Joint effects of ethnic enclave residence and ambient volatile organic compounds exposure on risk of gestational diabetes mellitus among Asian/Pacific Islander women in the United States.

BACKGROUND: Asian/Pacific Islander (API) communities in the United States often reside in metropolitan areas with distinct social and environmental attributes. Residence in an ethnic enclave, a socially distinct area, is associated with lower gestational diabetes mellitus (GDM) risk, yet exposure to high levels of air pollution, including volatile organic compounds (VOCS), is associated with increased GDM risk. We examined the joint effects of ethnic enclaves and VOCs to better understand GDM risk among API women, the group with the highest prevalence of GDM. METHODS: We examined 9069 API births in the Consortium on Safe Labor (19 hospitals, 2002-2008). API ethnic enclaves were defined as areas ≥66th percentile for percent API residents, dissimilarity (geographic dispersal of API and White residents), and isolation (degree that API individuals interact with another API individual). High levels of 14 volatile organic compounds (VOC) were defined as ≥75th percentile. Four joint categories were created for each VOC: Low VOC/Enclave (reference group), Low VOC/No Enclave, High VOC/Enclave, High VOC/No Enclave. GDM was reported in medical records. Hierarchical logistic regression estimated odds ratios (OR) and 95% confidence intervals (95%CI) between joint exposures and GDM, adjusted for maternal factors and area-level poverty. Risk was estimated for 3-months preconception and first trimester exposures. RESULTS: Enclave residence was associated with lower GDM risk regardless of VOC exposure. Preconception benzene exposure was associated with increased risk when women resided outside enclaves [High VOC/No Enclave (OR:3.45, 95%CI:1.77,6.72)], and the effect was somewhat mitigated within enclaves, [High VOC/Enclave (OR:2.07, 95%:1.09,3.94)]. Risks were similar for 12 of 14 VOCs during preconception and 10 of 14 during the first trimester. CONCLUSIONS: API residence in non-enclave areas is associated with higher GDM risk, regardless of VOC level. Ethnic enclave residence may mitigate effects of VOC exposure, perhaps due to lower stress levels. The potential benefit of ethnic enclaves warrants further study.

Associations between cumulative environmental quality and ten selected birth defects in Texas.

BACKGROUND: Causes of most birth defects are largely unknown. Genetics, maternal factors (e.g., age, smoking) and environmental exposures have all been linked to some birth defects, including neural tube, oral cleft, limb reduction, and gastroschisis; however, the contribution of cumulative exposures across several environmental domains in association with these defects is not well understood. METHODS: The Environmental Quality Index (EQI) and its domains (air, water, land, sociodemographic, built) were used to estimate county-level cumulative environmental exposures from 2006-2010 and matched to birth defects identified from Texas Birth Defects Registry and live birth records from births in years 2007-2010 (N = 1,610,709). Poisson regression models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for associations between 10 birth defects and the EQI. RESULTS: We observed some positive associations between worst environmental quality and neural tube, anencephaly, spina bifida, oral cleft, cleft palate, cleft lip with and without cleft palate, and gastroschisis [PR range: 1.12-1.55], but near null associations with limb reduction defects. Among domain specific results, we observed the strongest positive associations with the sociodemographic domain across birth defects but varied positive associations among the air and water domains, and negative or null associations with the land and built domains. Overall, few exposure-response patterns were evident. CONCLUSIONS: Our results highlight the complexities of cumulative, simultaneous environmental exposures in the prevalence rates of 10 selected birth defects. We were able to explore the impact of overall and domain specific environmental quality on birth defects and identify potential domain specific drivers of these associations.

Youth Assets and Associations With Adolescent Risk Taking.

BACKGROUND: Positive youth development emphasizes that adaptive features of adolescence may contribute to teenage pregnancy prevention. METHODS: Using data from approximately 1300 seventh-ninth graders, we describe positive youth development assets (external and internal) and their association with sexual risk taking. School-, sex-, and race/ethnicity-stratified logistic or linear models assessed associations between developmental assets and 6 outcomes (continuous attitudes about teenage sex and marriage, abstinence intentions, and nonsexual risk-taking behavior; dichotomous high risk-dating behavior, friends' sexual activity, and prior sexual activity). RESULTS: Associations between developmental assets and youth sexual behavior differed by school, sex, and race/ethnicity. White female respondents showed the most consistent associations between higher amounts of each of the positive youth development assets and attitudes and behaviors conducive to delaying sexual activity while black youth showed the fewest associations. CONCLUSION: These results contribute to the positive youth development literature by identifying that relationships between assets and adolescent risk differs by race and sex.

Pregnancy Outcomes and Documentation Status Among Latina Women: A Systematic Review.

Purpose: The impression that Latinas experience paradoxically good pregnancy outcomes in the United States persists, despite evidence showing that these outcomes are not enjoyed by all Latina subgroups. We conducted this systematic literature review to examine the relationship between documentation status and pregnancy outcomes among Latinas. Methods: This review synthesizes empirical evidence on this relationship; examines how these studies define and operationalize documentation status; and makes recommendations of how a more comprehensive methodological approach can guide public health research on the impact of documentation status on Latina immigrants to the United States. We searched the literature within PubMed, Web of Science, Academic Search Premier, and Google Scholar in 2017 for relevant studies. Results: Based on stringent inclusion criteria, we retained nine studies for analysis. Conclusion: We found that evidence for the impact of documentation status on pregnancy outcomes among Latinas is not conclusive. We believe the divergence in our findings is, in part, due to variation in: conceptualization of how documentation status impacts pregnancy outcomes, sample populations, definitions of exposures and outcomes, and contextual factors included in models. Specific analytic challenges around sampling, measurement, and data analysis are identified. Suggestions for future research are offered regarding measurement of documentation status. Findings highlight the need for increased attention to documentation as an influence on Latina pregnancy outcomes.

The tipping point: could increasing the subminimum wage reduce poverty-related antenatal stressors in U.S. women?

PURPOSE: Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage, contributing to economic hardship. Poverty-related antenatal stress has deleterious health effects for women and their children. The purpose of this study was to investigate the effects of increasing the state-level subminimum wage (currently $2.13 per hour) on poverty-related antenatal stress for women in the United States. METHODS: Utilizing a difference-in-differences approach comparing state wage policies over time, we estimated the impact of increases in the subminimum wage on poverty-related antenatal stress using data from 35 states participating in the Pregnancy Risk Assessment Monitoring System between 2004 and 2014, linked to state-level wage laws, census, and antipoverty policy data. RESULTS: The effect of increasing the subminimum wage on poverty-related stress differed by year and sociodemographics. Wage increases in 2014 were associated with the largest decreases in stress for unmarried women of color with less than a college degree, a population that we estimated would have experienced a 19.7% reduction in stress from 2004 to 2014 if subminimum wage was equivalent to the federal minimum wage. CONCLUSIONS: Increasing the subminimum wage can reduce poverty-related stress and may be a potential intervention for reducing poor health outcomes.

Self-reported depression and social support are associated with egocentric network characteristics of HIV-infected women of color.

BACKGROUND: We explore the social network characteristics associated with depressive symptoms and social support among HIV-infected women of color (WOC). METHODS: Network data were collected from 87 HIV-infected WOC at an academic Infectious Disease clinic in the United States (US) south. With validated instruments, interviewers also asked about depressive symptoms, social support, and treatment-specific social support. Linear regression models resulted in beta coefficients and 95% confidence intervals for the relationships among network characteristics, depression, and support provision. RESULTS: Financial support provision was associated with lower reported depressive symptoms while emotional support provision was associated with increased reported social support. Talking less than daily to the first person named in her network, the primary alter, was associated with a nearly 3-point decrease in reported social support for respondents. Having people in their social network who knew their HIV status was also important. CONCLUSIONS: We found that both functional and structural social network characteristics contributed to perceptions of support by HIV-infected WOC.

A nationwide investigation of the impact of the tipped worker subminimum wage on infant size for gestational age.

Tipped workers, primarily women of reproductive-age, can be paid a "subminimum wage" 71% lower than the federal minimum wage. We estimated the effects of increasing the state-level tipped worker subminimum wage (federally, $2.13 per hour) on infant size for gestational age in the US as infants born small or large are at risk for poor health across the lifecourse. Utilizing unconditional quantile regression and difference-in-differences analysis of data from 2004 to 2016 Vital Statistics Natality Files (N = 41,219,953 mother-infant dyads), linked to state-level wage laws, census, and antipoverty policy data, we estimated the effect of increasing the subminimum wage on birthweight standardized for gestational age (BWz). Smallest and largest infants are defined as those in the 5th and 95th BWz percentiles, respectively. Increases in the subminimum wage affected the BWz distribution. When compared to a static wage of $2.13 for the duration of the study period, wage set to 100% of the federal minimum ($5.15-$7.25) was associated with an increase in BWz of 0.024 (95% CI: 0.004, 0.045) for the smallest infants and a decrease by 0.041 (95% CI: -0.054, -0.029) for the largest infants. Increasing the subminimum wage may be one strategy to promote healthier birthweight in infants.

Ethnic Enclaves and Pregnancy and Behavior Outcomes Among Asian/Pacific Islanders in the USA.

OBJECTIVES: Ethnic enclaves are ethnically, spatially, and socially distinct communities that may promote health through access to culturally appropriate resources and reduced exposure to discrimination. This study examined ethnic enclave residence and pregnancy outcomes among Asian/Pacific Islander (API) women in the USA. DESIGN: We examined 9206 API births in the Consortium on Safe Labor (2002-2008). Ethnic enclaves were defined as hospital regions with high percentage of API residents (> 4%), high dissimilarity index (> 0.41; distribution of API and white residents within a geographic area), and high isolation index (> 0.03; interaction between API and white residents in an area). Gestational diabetes mellitus (GDM), preterm birth (PTB), small for gestational age (SGA), and smoking and alcohol use during pregnancy were reported in medical records supplemented with ICD-9 codes. Hierarchical logistic regression models estimated associations between ethnic enclaves and pregnancy outcomes, adjusted for maternal factors, area-level poverty, and air pollution. RESULTS: Women in enclaves had lower odds of GDM (OR 0.61; 95%CI 0.45, 0.82), PTB (OR 0.74; 95%CI 0.56, 0.99), and SGA (OR 0.68; 95%CI 0.52, 0.89) compared with women in non-enclaves. Prenatal smoking and alcohol use appeared less likely in enclaves, but estimates were imprecise. Within enclaves, about 10.5% of homes speak an API language, compared with 6.0% in non-enclaves. The mean percent of foreign-born API populations was 67.4% in enclaves and 68.8% in non-enclaves. CONCLUSIONS: API women residing in ethnic enclaves had better pregnancy outcomes than API women residing in non-enclave areas. Access to culturally appropriate social supports and resources may be important for health promotion among API populations.

Divergent trends in life expectancy across the rural-urban gradient and association with specific racial proportions in the contiguous USA 2000-2005.

OBJECTIVES: To estimate county-level adult life expectancy for Whites, Black/African Americans (Black), American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (Asian) populations and assess the difference across racial groups in the relationship among life expectancy, rurality and specific race proportion. METHODS: We used individual-level death data to estimate county-level life expectancy at age 25 (e25) for Whites, Black, AIAN and Asian in the contiguous USA for 2000-2005. Race-sex-stratified models were used to examine the associations among e25, rurality and specific race proportion, adjusted for socioeconomic variables. RESULTS: Lower e25 was found in the central USA for AIANs and in the west coast for Asians. We found higher e25 in the most rural areas for Whites but in the most urban areas for AIAN and Asians. The associations between specific race proportion and e25 were positive or null for Whites but were negative for Blacks, AIAN, and Asians. The relationship between specific race proportion and e25 varied across rurality. CONCLUSIONS: Identifying differences in adult life expectancy, both across and within racial groups, provides new insights into the geographic determinants of life expectancy disparities.

Air pollution, neighborhood deprivation, and autism spectrum disorder in the Study to Explore Early Development.

BACKGROUND: To examine whether neighborhood deprivation modifies the association between early life air pollution exposure and autism spectrum disorder (ASD), we used resources from a multisite case-control study, the Study to Explore Early Development. METHODS: Cases were 674 children with confirmed ASD born in 2003-2006; controls were 855 randomly sampled children born during the same time period and residents of the same geographic areas as cases. Air pollution was assessed by roadway proximity and particulate matter <2.5 µm (PM2.5) exposure during pregnancy and first year of life. To characterize neighborhood deprivation, an index was created based on eight census tract-level socioeconomic status-related parameters. The continuous index was categorized into tertiles, representing low, moderate, and high deprivation. Logistic regression was used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs). RESULTS: Neighborhood deprivation modified (P for interaction = 0.08) the association between PM2.5 exposure during the first year of life and ASD, with a stronger association for those living in high (OR = 2.42, 95% CI = 1.20, 4.86) rather than moderate (OR=1.21, 95% CI = 0.67, 2.17) or low (OR=1.46, 95% CI = 0.80, 2.65) deprivation neighborhoods. Departure from additivity or multiplicativity was not observed for roadway proximity or exposures during pregnancy. CONCLUSION: These results provide suggestive evidence of interaction between neighborhood deprivation and PM2.5 exposure during the first year of life in association with ASD.

Analyzing Policies Through a DOHaD Lens: What Can We Learn?

Social, health, and environmental policies are critical tools for providing the conditions needed for healthy populations. However, current policy analyses fall short of capturing their full potential impacts across the life course and from generation to generation. We argue that the field of Developmental Origins of Health and Disease (DOHaD), a conceptual and research framework positing that early life experiences significantly affect health trajectories across the lifespan and into future generations, provides an important lens through which to analyze social policies. To illustrate this point, we synthesized evidence related to policies from three domains-family leave, nutrition, and housing-to examine the health implications for multiple generations. We selected these policy domains because they represent increasing distance from a reproductive health focus, each with a growing evidence base to support a potential impact on pregnant women and their offspring. Each of these examples represents an opportunity to extend our understanding of policy impact using a DOHaD lens, taking into account the potential life course and intergenerational effects that have previously been overlooked.

Associations between environmental quality and infant mortality in the United States, 2000-2005.

BACKGROUND: The United States (U.S.) suffers from high infant mortality (IM) rates and there are significant racial/ethnic differences in these rates. Prior studies on the environment and infant mortality are generally limited to singular exposures. We utilize the Environmental Quality Index (EQI), a measure of cumulative environmental exposure (across air, water, land, sociodemographic, and land domains) for U.S. counties from 2000 to 2005, to investigate associations between ambient environment and IM across maternal race/ethnicity. METHODS: We linked 2000-2005 infant data from the U.S. Centers for Disease Control and Prevention to the EQI (n = 22,702,529; 144,741 deaths). We utilized multi-level regression to estimate associations between quartiles of county-level EQI and IM. We also considered associations between quartiles of county level domain specific indices with IM. We controlled for rural-urban status (RUCC1: urban, metropolitan; RUCC2: urban, non-metropolitan; RUCC3: less urbanized; RUCC4: thinly populated), maternal age, maternal education, marital status, infant sex, and stratified on race/ethnicity. Additionally, we estimated associations for linear combinations of environmental quality and rural-urban status. RESULTS: We found a mix of positive, negative, and null associations and our findings varied across domain and race/ethnicity. Poorer overall environmental quality was associated with decreased odds among Non-Hispanic whites (OR and 95% CI: EQIQ4 (ref. EQIQ1): 0.84[0.80,0.89]). For Non-Hispanic blacks and Hispanics, some increased odds were observed. Poorer air quality was monotonically associated with increased odds among Non-Hispanic whites (airQ4 (ref. airQ1): 1.05[0.99,1.11]) and blacks (airQ4 (ref. airQ1): 1.09 [0.9,1.31]). Rural status was associated with increased IM odds among Hispanics (RUCC4-Q4:1.36[1.04,1.78]; RUCC1-Q4: 1.04[0.92,1.16], ref. for both RUCC1-Q1). CONCLUSIONS: This study is the first to report on associations between ambient environmental quality and IM across the United States. It corroborates prior research suggesting an association between air pollution and IM and identifies residence in thinly populated (rural) areas as a potential risk factor towards IM amongst Hispanics. Some of the counterintuitive findings highlight the need for additional research into potentially differential drivers of environmental quality across the rural-urban continuum, especially with regards to the sociodemographic environment.

The association between physical inactivity and obesity is modified by five domains of environmental quality in U.S. adults: A cross-sectional study.

Physical inactivity is a primary contributor to the obesity epidemic, but may be promoted or hindered by environmental factors. To examine how cumulative environmental quality may modify the inactivity-obesity relationship, we conducted a cross-sectional study by linking county-level Behavioral Risk Factor Surveillance System data with the Environmental Quality Index (EQI), a composite measure of five environmental domains (air, water, land, built, sociodemographic) across all U.S. counties. We estimated the county-level association (N = 3,137 counties) between 2009 age-adjusted leisure-time physical inactivity (LTPIA) and 2010 age-adjusted obesity from BRFSS across EQI tertiles using multi-level linear regression, with a random intercept for state, adjusted for percent minority and rural-urban status. We modelled overall and sex-specific estimates, reporting prevalence differences (PD) and 95% confidence intervals (CI). In the overall population, the PD increased from best (PD = 0.341 (95% CI: 0.287, 0.396)) to worst (PD = 0.645 (95% CI: 0.599, 0.690)) EQI tertile. We observed similar trends in males from best (PD = 0.244 (95% CI: 0.194, 0.294)) to worst (PD = 0.601 (95% CI: 0.556, 0.647)) quality environments, and in females from best (PD = 0.446 (95% CI: 0.385, 0.507)) to worst (PD = 0.655 (95% CI: 0.607, 0.703)). We found that poor environmental quality exacerbates the LTPIA-obesity relationship. Efforts to improve obesity through LTPIA may benefit from considering this relationship.

Associations between environmental quality and adult asthma prevalence in medical claims data.

As of 2014, approximately 7.4% of U.S. adults had current asthma. The etiology of asthma is complex, involving genetics, behavior, and environmental factors. To explore the association between cumulative environmental quality and asthma prevalence in U.S. adults, we linked the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) to the MarketScan® Commercial Claims and Encounters Database. The EQI is a summary measure of five environmental domains (air, water, land, built, sociodemographic). We defined asthma as having at least 2 claims during the study period, 2003-2013. We used a Bayesian approach with non-informative priors, implementing mixed-effects regression modeling with a Poisson link function. Fixed effects variables were EQI, sex, race, and age. Random effects were counties. We modeled quintiles of the EQI comparing higher quintiles (worse quality) to lowest quintile (best quality) to estimate prevalence ratios (PR) and credible intervals (CIs). We estimated associations using the cumulative EQI and domain-specific EQIs; we assessed U.S. overall (non-stratified) as well as stratified by rural-urban continuum codes (RUCC) to assess rural/urban heterogeneity. Among the 71,577,118 U.S. adults with medical claims who could be geocoded to county of residence, 1,147,564 (1.6%) met the asthma definition. Worse environmental quality was associated with increased asthma prevalence using the non-RUCC-stratified cumulative EQI, comparing the worst to best EQI quintile (PR:1.27; 95% CI: 1.21, 1.34). Patterns varied among different EQI domains, as well as by rural/urban status. Poor environmental quality may increase asthma prevalence, but domain-specific drivers may operate differently depending on rural/urban status.