Association Between Lack of Access to a Neighborhood Park and High Blood Pressure in the Philadelphia Metropolitan Area.

INTRODUCTION: Studies have shown a lower risk of high blood pressure (HBP) among people who live near parks; however, little information exists on how feeling safe and comfortable visiting the park affects blood pressure. We identified associations between neighborhood park access, comfort visiting a park, and HBP to understand how these factors may contribute to disparities in HBP prevalence. METHODS: The 2018 Southeastern Pennsylvania Household Health Survey of 3,600 residents in the Philadelphia metropolitan area asked if respondents had ever been told they had HBP and whether they had a neighborhood park or outdoor space that they were comfortable visiting during the day. To assess the association between park access and HBP, we built multilevel logistic models to account for variation in HBP by zip code. We examined the effect modification of perceptions of park access (having a neighborhood park, not having a neighborhood park, or having a neighborhood park but not comfortable visiting it) and HBP by race, education, and poverty status. RESULTS: Both not having a neighborhood park and having a park but not feeling comfortable visiting it were associated with higher unadjusted odds of HBP, 70% and 90%, respectively, compared with having a neighborhood park. Adjusted odds ratios for the lack-of-park responses remained significant (no neighborhood park, adjusted odds ratio [aOR] = 1.4; 95% CI, 1.1-1.7; neighborhood park but not comfortable visiting, aOR = 1.4; 95% CI, 1.03-2.0). A significant gradient was observed for Black respondents compared with White respondents with odds of HBP increasing by perceptions of park access (aOR = 1.95 for people with a park; aOR = 2.69 for those with no park; aOR = 3.5 for people with a park that they are not comfortable visiting). CONCLUSION: Even accounting for other risk factors for HBP, not having a neighborhood park or not feeling comfortable visiting one may influence individual HBP. Neighborhood factors that deter park access may contribute to racial disparities in HBP.

Individual- and neighborhood-level characteristics of lung cancer screening participants undergoing telemedicine shared decision making.

BACKGROUND: Although lung cancer screening (LCS) for high-risk individuals reduces lung cancer mortality in clinical trial settings, many questions remain about how to implement high-quality LCS in real-world programs. With the increasing use of telemedicine in healthcare, studies examining this approach in the context of LCS are urgently needed. We aimed to identify sociodemographic and other factors associated with screening completion among individuals undergoing telemedicine Shared Decision Making (SDM) for LCS. METHODS: This retrospective study examined patients who completed Shared Decision Making (SDM) via telemedicine between May 4, 2020 - March 18, 2021 in a centralized LCS program. Individuals were categorized into Complete Screening vs. Incomplete Screening subgroups based on the status of subsequent LDCT completion. A multi-level, multivariate model was constructed to identify factors associated with incomplete screening. RESULTS: Among individuals undergoing telemedicine SDM during the study period, 20.6% did not complete a LDCT scan. Bivariate analysis demonstrated that Black/African-American race, Medicaid insurance status, and new patient type were associated with greater odds of incomplete screening. On multi-level, multivariate analysis, individuals who were new patients undergoing baseline LDCT or resided in a census tract with a high level of socioeconomic deprivation had significantly higher odds of incomplete screening. Individuals with a greater level of education experienced lower odds of incomplete screening. CONCLUSIONS: Among high-risk individuals undergoing telemedicine SDM for LCS, predictors of incomplete screening included low education, high neighborhood-level deprivation, and new patient type. Future research should focus on testing implementation strategies to improve LDCT completion rates while leveraging telemedicine for high-quality LCS.

A novel method for measuring the burden of breast cancer in neighborhoods.

Community-based breast cancer prevention efforts often focus on women who live in the same neighborhoods, as they tend to have similar demographic characteristics, health behaviors, and environmental exposures; yet little research describes methods of selecting neighborhoods of focus for community-based cancer prevention interventions. Studies frequently use demographics from census data, or single breast cancer outcomes (e.g., mortality, morbidity) in order to choose neighborhoods of focus for breast cancer interventions, which may not be optimal. This study presents a novel method for measuring the burden of breast cancer among neighborhoods that could be used for selecting neighborhoods of focus. In this study, we 1) calculate a metric composed of multiple breast cancer outcomes to describe the burden of breast cancer in census tracts Philadelphia, PA, USA; 2) map the neighborhoods with the greatest breast cancer burden; and 3) compare census tracts with the highest burden of breast cancer to those with demographics sometimes used for geo-based prioritization, i.e., race and income. The results of our study showed that race or income may not be appropriate proxies for neighborhood breast cancer burden; comparing the breast cancer burden with demographics at the census tract level, we found few overlaps with the highest percentage African American or the lowest median incomes. Agencies implementing community-based breast cancer interventions should consider this method to inform the selection of neighborhoods for breast cancer prevention interventions, including education, screening, and treatment.

Predictors of consenting to participate in a clinical trial among urban cancer patients.

BACKGROUND: Patient participation in clinical trials is influenced by demographic and other individual level characteristics. However, there is less research on the role of geography and neighborhood-level factors on clinical trial participation. This study identifies the demographic, clinical, geographic, and neighborhood predictors of consenting to a clinical trial among cancer patients at a large, urban, NCI-designated cancer center in the Mid-Atlantic region. METHODS: We used demographic and clinical data from patients diagnosed with cancer between 2015 and 2017. We geocoded patient addresses and calculated driving distance to the cancer center. Additionally, we linked patient data to neighborhood-level educational attainment, social capital and cancer prevalence. Finally, we used generalized linear mixed-effects conditional logistic regression to identify individual and neighborhood-level predictors of consenting to a clinical trial. RESULTS: Patients with higher odds of consenting to trials were: Non-Hispanic White, aged 50-69, diagnosed with breast, GI, head/neck, hematologic, or certain solid tumor cancers, those with cancers at regional stage, never/former tobacco users, and those with the highest neighborhood social capital index. Patients who lived further from the cancer center had higher odds of consenting to a trial. With every 1-km increase in residential distance, there was a 4% increase in the odds that patients would consent to a trial. Neither of the additional neighborhood-level variables predicted consenting to a clinical trial. CONCLUSIONS: This study identifies important demographic, patient-level, and geographic factors associated with consenting to cancer clinical trials, and lays the groundwork for future research exploring the role of neighborhood-level factors in clinical trial participation.

A Descriptive Analysis of Mass Shootings in the United States From 2010 to 2020: The Relationship Between Firearm Dealership Density and Proximity to Mass Shooting Sites and a Comparison With McDonald's and Starbucks Retailers.

The public health community needs to better understand the complex factors that contribute to mass shootings in the United States (US). We explored how firearm dealership density related to geographic distance from mass shooting sites in the US in 2010-2020, and compared it with the corresponding density of Starbucks (Starbucks Corporation, Seattle, Washington, United States) and McDonald's (McDonald's Corporation, Chicago, Illinois, United States) outlets. We obtained locations of firearm dealerships, Starbucks, and McDonald's retailers, as well as mass shootings across the contiguous US from 2010 to 2020. We mapped buffer rings, at 1, 5, 10, 30, and 50 miles around the locations of each mass shooting. We compared the per area and per population density of the dealerships and the two types of retailers around mass shooting sites within each buffer ring. We identified 67 mass shootings from 2010-2020. We mapped 54,722 firearm dealerships, with 28.1% located within 50 miles of mass shootings. Within a 50-mile radius of shooting events, there were an average of 0.30 dealerships, while there were only 0.14 Starbucks and 0.12 McDonald's outlets per 10 square miles. There was an incremental reduction in the density of firearm dealerships, Starbucks, and McDonald's as the distance from the mass shooting site increased. Density per population did not show a similar relationship. Our findings suggest that the availability of firearms deserves more study as a contributing factor to mass shootings in the US. The high number, area, and population density of firearm dealerships compared to the other two retailers illuminate how numerous firearm dealerships are compared to common retailers in the US.

Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines.

The National Lung Screening Trial established the benefits of low-dose computed tomography for lung cancer screening (LCS) to identify lung cancer at earlier stages. In February 2021, the US Preventive Services Task Force (USPSTF) revised the eligibility recommendations to increase the number of high-risk individuals eligible for LCS and, in effect, expand screening eligibility for vulnerable populations. One strategy for facilitating LCS is to implement targeted screening in geographic areas with the greatest need. In Philadelphia, although neighborhood smoking rates have been defined, it is not known which neighborhoods have the greatest number of people eligible for LCS. In this study, the authors estimate eligibility for LCS within Philadelphia neighborhoods using both previous and current USPSTF guidelines. They used the Public Health Management Corporation's Household Health Survey from 2010, 2012, and 2015 to identify the number of people within ever-smoker groups (current every day, current occasional, and former smokers) by neighborhood in Philadelphia. Using the 2015 National Health Interview Survey (NHIS) Cancer Supplement, they identified the percentages within ever-smoker groups that were LCS eligible using the previous and current USPSTF guidelines. Finally, they applied the percentages eligible for the ever-smoker groups from the NHIS to the numbers in these groups within Philadelphia neighborhoods. They found that the number of Philadelphians eligible for LCS increased from 41,946 to 89,231 after the revised USPSTF guidelines. The current USPSTF guidelines increased eligibility for LCS within all Philadelphia neighborhoods, with the greatest increases in the River Wards planning district. Local providers should use these results to prioritize LCS services within neighborhoods with greatest eligibility.

Acculturation and Hypertension Diagnoses Among Hispanics in California.

BACKGROUND: Among U.S. Hispanic immigrants and all other Hispanics living in the USA, heart disease is the leading cause of death. Meanwhile, the prevalence of hypertension among Mexican Americans, a subgroup of the U.S. Hispanic population, is rising. The purpose of this study was to estimate the prevalence of hypertension diagnosis and to determine the association between acculturation and hypertension among Mexican Americans and Other Hispanics in California. METHODS: Using data from the 2014 California Health Interview Survey (CHIS), we performed multivariable logistic regression to identify whether acculturation (measured by self-reported duration of U.S. residence) predicted hypertension diagnoses, after controlling for sociodemographic characteristics (e.g., age, gender, poverty level), body mass index, health insurance coverage, and cigarette smoking. RESULTS: Of 3793 Hispanics who participated in the survey, 81.8% were Mexican Americans, and 18.2% were Other Hispanics. The prevalence of hypertension among Hispanics was 24.0% (95% CI: 21.5-26.7), which was lower than that of African Americans (40.3%, 95% CI 34.2-46.7) and Whites (31.8%, 95% CI: 29.7-34.0). In the multivariable regression analysis, acculturation was associated with hypertension for Mexican Americans (aOR = 1.71, 95% CI, 1.24-2.36) and Other Hispanics (aOR = 2.77, 95% CI, 1.71-4.51). CONCLUSION: The results show a positive association between acculturation in the USA and hypertension diagnoses among Mexican Americans and Other Hispanics. The findings can help public health practitioners, medical providers, policymakers, and others better understand the potential influences of acculturation on Hispanic immigrants' health and inform the creation of culturally sensitive health promotion materials.

A Method for Investigating Access to Diaper Changing Stations in Restaurants.

Parents and caretakers of young children need diaper changing stations (DCSs) to fully utilize public and commercial spaces, but few studies measure their availability. We developed a method for assessing the availability of DCSs in restaurant restrooms through phone interviews and validated the results using in-person visits. This study tested a phone interview methodology for investigating availability within restaurants, and the extent to which DCSs were accessible to both male and female caregivers. In May of 2019, phone interviews were conducted to survey the employees of 60 Philadelphia restaurants with a public restroom available to patrons to determine whether they had unisex or gendered restrooms, a DCS, and accessibility to a DCS for both male and female caregivers. Each interview was followed by an in-person audit. During phone interviews, 10 (16.7%) restaurants reported having and 50 (83.3%) reported not having DCSs. In-person audits confirmed 59 of 60 (98.3%) phone interview responses about the presence of DCSs (Cohen's kappa: 0.94) and 55 of 60 (91.7%) reports of restroom types (Cohen's kappa: 0.83). In this study, the phone interview methodology accurately identified the presence of DCSs in restaurants. This methodology can be used to identify disparities and to advocate for policy changes to improve access to DCSs for all who need them.

Racial Differences in Lung Cancer Screening Beliefs and Screening Adherence.

BACKGROUND: One challenge in high-quality lung cancer screening (LCS) is maintaining adherence with annual and short-interval follow-up screens among high-risk individuals who have undergone baseline low-dose CT (LDCT). This study aimed to characterize attitudes and beliefs toward lung cancer and LCS and to identify factors associated with LCS adherence. METHODS: We administered a questionnaire to 269 LCS participants to assess attitudes and beliefs toward lung cancer and LCS. Clinical data including sociodemographics and screening adherence were obtained from the LCS Program Registry. RESULTS: African-American individuals had significantly greater lung cancer worries compared with Whites (6.10 vs. 4.66, P < .001). In making the decision to undergo LCS, African-American participants described screening convenience and cost as very important factors significantly more frequently than Whites (60% vs. 26.8%, P< .001 and 58.4% vs. 37.8%, P = .001; respectively). African-American individuals with greater than high school education had significantly higher odds of LCS adherence (aOR 2.55; 95% CI, 1.14-5.60) than Whites with less than high school education. Participants who described screening convenience and cost as "very important" had significantly lower odds of completing screening follow-up after adjusting for demographic and other factors (aOR 0.56; 95% CI, 0.33-0.97 and aOR 0.54; 95% CI, 0.33-0.91, respectively). CONCLUSION: Racial differences in beliefs about lung cancer and LCS exist among African-American and White individuals enrolled in an LCS program. Cost, convenience, and low educational attainment may be barriers to LCS adherence, specifically among African-American individuals. IMPACT: More research is needed on how barriers can be overcome to improve LCS adherence.

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up.

BACKGROUND: Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans. METHODS: A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes. RESULTS: After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories. CONCLUSIONS: Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs.

Do Employees From Less-Healthy Communities Use More Care and Cost More? Seeking to Establish a Business Case for Investment in Community Health.

INTRODUCTION: Few studies have examined the impact of community health on employers. We explored whether employed adults and their adult dependents living in less-healthy communities in the greater Philadelphia region used more care and incurred higher costs to employers than employees from healthier communities. METHODS: We used a multi-employer database to identify adult employees and dependents with continuous employment and mapped them to 31 zip code regions. We calculated community health scores at the regional level, by using metrics similar to the Robert Wood Johnson Foundation (RWJF) County Health Rankings but with local data. We used descriptive analyses and multilevel linear modeling to explore relationships between community health and 3 outcome variables: emergency department (ED) use, hospital use, and paid claims. Business leaders reviewed findings and offered insights on preparedness to invest in community health improvement. RESULTS: Poorer community health was associated with high use of ED services, after controlling for age and sex. After including a summary measure of racial composition at the zip code region level, the relationship between community health and ED use became nonsignificant. No significant relationships between community health and hospitalizations or paid claims were identified. Business leaders expressed interest in further understanding health needs of communities where their employees live. CONCLUSION: The health of communities in which adult employees and dependents live was associated with ED use, but similar relationships were not seen for hospitalizations or paid claims. This finding suggests a need for more primary care access. Despite limited quantitative evidence, business leaders expressed interest in guidance on investing in community health improvement.

Mapping the Burden of Chronic Diseases in Delaware for Public Health Decision Making.

Public health decision-makers need to consider geographic differences in rates of chronic disease risk factors and outcomes in order to focus intervention efforts on populations exhibiting the greatest burden of disease. Increasingly, public health agencies are using geographic information systems (GIS) to analyze area-based variations and identify geographic priority areas for health promoting interventions. The articles in this issue are descriptive studies presenting the geographic distribution of select chronic disease risk factors and outcomes among Delaware communities. These studies emerged from a collaboration between the Christiana Care Value Institute and the Jefferson College of Population Health. These studies show that the burden of chronic diseases is not distributed evenly among communities in Delaware. The results of these studies add to the evidence base about public health in Delaware, and should inform public health practitioners working to improve the health of Delaware communities.

A Prostate Cancer Composite Score to Identify High Burden Neighborhoods.

This study presents a novel geo-based metric to identify neighborhoods with high burdens of prostate cancer, and compares this metric to other methods to prioritize neighborhoods for prostate cancer interventions. We geocoded prostate cancer patient data (n = 10,750) from the Pennsylvania cancer registry from 2005 to 2014 by Philadelphia census tract (CT) to create standardized incidence ratios (SIRs), mortality ratios (SMRs), and mean prostate cancer aggressiveness. We created a prostate cancer composite (PCa composite) variable to describe CTs by mean-centering and standard deviation-scaling the SMR, SIR, and mean aggressiveness variables and summing them. We mapped CTs with the 25 highest PCa composite scores and compared these neighborhoods to CTs with the 25 highest percent African American residents and the 25 lowest median household incomes. The mean PCa composite score among the 25 highest CTs was 4.65. Only seven CTs in Philadelphia had both one of the highest PCa composite scores and the highest percent African American residents. Only five CTs had both the highest PCa composites and the lowest median incomes. Mean PCa composite scores among CTs with the highest percent African American residents and lowest median incomes were 2.08 and 1.19, respectively. The PCa composite score is an accurate metric for prioritizing neighborhoods based on burden. If neighborhoods were prioritized based on percent African American or median income, priority neighborhoods would have been very different and not based on PCa burden. These methods can be utilized by public health decision-makers when tasked to prioritize and select neighborhoods for cancer interventions.

Characteristics Associated with Smoking Among Patrons of Three Philadelphia Parks.

To create healthy public spaces, Philadelphia prohibits smoking in city-owned and operated parks. Identifying the prevalence and characteristics of smoking in Philadelphia Parks would be useful for monitoring purposes; yet no studies have collected this data. This study identified the prevalence and characteristics of smoking among adult patrons entering three Philadelphia Parks (Washington Square Park, Independence Square Park, and Louis Kahn Park). During May and June 2016, we observed patrons entering the parks on Thursday afternoons. We used handheld electronic devices to categorize patrons by smoking status, age, gender, and tobacco product. We used logistic regression to assess the association of these variables with smoking. We observed 4822 people, of which 10.6% were children. Smoking was noted among 2.6% of adults in Washington Square Park, 2.6% of adults in Independence Square Park, and 7.7% of adults in Louis Kahn Park. Patronizing Louis Kahn Park was associated with greater likelihood of smoking (OR 3.11, CI 1.77-5.46) compared to Washington Square. Males were more likely than females to smoke (OR 1.45, CI 1.01-2.09). Higher likelihood of smoking among males concurs with previous studies. Higher prevalence in Louis Kahn Park may be due to differences in park patron demographics compared to other parks. Results could be used as a baseline for periodic monitoring of smoking in parks in order to inform implementation of the smoke-free park policy in Philadelphia.

Secondhand smoke exposure and other correlates of susceptibility to smoking: a propensity score matching approach.

Secondhand smoke (SHS) exposure is responsible for numerous diseases of the lungs and other bodily systems among children. In addition to the adverse health effects of SHS exposure, studies show that children exposed to SHS are more likely to smoke in adolescence. Susceptibility to smoking is a measure used to identify adolescent never-smokers who are at risk for smoking. Limited research has been conducted on the influence of SHS on susceptibility to smoking. The purpose of this study was to determine a robust measure of the strength of correlation between SHS exposure and susceptibility to smoking among never-smoking U.S. adolescents. This study used data from the 2009 National Youth Tobacco Survey to identify predictors of susceptibility to smoking in the full (pre-match) sample of adolescents and a smaller (post-match) sample created by propensity score matching. Results showed a significant association between SHS exposure and susceptibility to smoking among never-smoking adolescents in the pre-match (OR=1.47) and post-match (OR=1.52) samples. The odds ratio increase after matching suggests that the strength of the relationship was underestimated in the pre-match sample. Other significant correlates of susceptibility to smoking identified include: gender, race/ethnicity, personal income, smoke-free home rules, number of smoking friends, perception of SHS harm, perceived benefits of smoking, and exposure to pro-tobacco media messages. The use of propensity score matching procedures reduced bias in the post-match sample, and provided a more robust estimate of the influence of SHS exposure on susceptibility to smoking, compared to the pre-match sample estimates.

Secondhand smoke exposure in cars and rooms: trend comparisons among subpopulations of nonsmoking U.S. middle and high school students.

INTRODUCTION: Young people in the United States are exposed to secondhand smoke (SHS) primarily in 2 settings: homes and cars. Recently, researchers reported that the prevalence of U.S students exposed to SHS in cars decreased from 2000 to 2009; however, comparisons of trends across school levels, gender, and racial/ethnic groups were not assessed. Moreover, no studies have examined trends of exposure to SHS in rooms. METHODS: We used data from the 2000, 2002, 2004, 2006, and 2009 waves of the National Youth Tobacco Survey, a nationally representative cross-sectional survey of U.S. middle and high school students. For SHS in cars and rooms, we identified exposure trends among nonsmokers from 2000 to 2009 and compared trends across subpopulations with binary logistic regression. RESULTS: We identified significant downward linear trends in SHS in cars and rooms for nearly all measured subpopulations of nonsmoking students from 2000 to 2009. SHS exposure in cars and rooms declined at a significantly greater rate for males than for females. SHS exposure in cars declined at a significantly greater rate for non-Hispanic (NH) Blacks than for NH Whites. SHS exposure in rooms declined at a significantly greater rate for NH Whites than for Hispanics and Native Hawaiians/Pacific Islanders. CONCLUSIONS: Although prevalence of exposure to SHS in cars and rooms among nonsmoking U.S. middle and high school students has declined from 2000 to 2009, the rates of decline were not equal across genders and racial/ethnic groups. Identification of these differing rates of exposure can help the public health community advocate for interventions focused on reducing adolescent SHS exposure.

National, regional, and global trends in adult overweight and obesity prevalences.

BACKGROUND: Overweight and obesity prevalence are commonly used for public and policy communication of the extent of the obesity epidemic, yet comparable estimates of trends in overweight and obesity prevalence by country are not available. METHODS: We estimated trends between 1980 and 2008 in overweight and obesity prevalence and their uncertainty for adults 20 years of age and older in 199 countries and territories. Data were from a previous study, which used a Bayesian hierarchical model to estimate mean body mass index (BMI) based on published and unpublished health examination surveys and epidemiologic studies. Here, we used the estimated mean BMIs in a regression model to predict overweight and obesity prevalence by age, country, year, and sex. The uncertainty of the estimates included both those of the Bayesian hierarchical model and the uncertainty due to cross-walking from mean BMI to overweight and obesity prevalence. RESULTS: The global age-standardized prevalence of obesity nearly doubled from 6.4% (95% uncertainty interval 5.7-7.2%) in 1980 to 12.0% (11.5-12.5%) in 2008. Half of this rise occurred in the 20 years between 1980 and 2000, and half occurred in the 8 years between 2000 and 2008. The age-standardized prevalence of overweight increased from 24.6% (22.7-26.7%) to 34.4% (33.2-35.5%) during the same 28-year period. In 2008, female obesity prevalence ranged from 1.4% (0.7-2.2%) in Bangladesh and 1.5% (0.9-2.4%) in Madagascar to 70.4% (61.9-78.9%) in Tonga and 74.8% (66.7-82.1%) in Nauru. Male obesity was below 1% in Bangladesh, Democratic Republic of the Congo, and Ethiopia, and was highest in Cook Islands (60.1%, 52.6-67.6%) and Nauru (67.9%, 60.5-75.0%). CONCLUSIONS: Globally, the prevalence of overweight and obesity has increased since 1980, and the increase has accelerated. Although obesity increased in most countries, levels and trends varied substantially. These data on trends in overweight and obesity may be used to set targets for obesity prevalence as requested at the United Nations high-level meeting on Prevention and Control of NCDs.