Area-level Socioeconomic Status Research Articles

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study.

The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica. A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'. Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU. This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Cancer inequalities in incidence and mortality in the State of São Paulo, Brazil 2001-17.

Cancer disparities exist between and within countries; we sought to compare cancer-specific incidence and mortality according to area-level socioeconomic status (SES) in the State of São Paulo, Brazil. Cancer cases diagnosed 2003-2017 in the Barretos region and 2001-2015 in the municipality of São Paulo were obtained from the respective cancer registries. Corresponding cancer deaths were obtained from a Brazilian public government database. Age-standardized rates for all cancer combined and the six most common cancers were calculated by SES quartiles. There were 14,628 cancer cases and 7513 cancer deaths in Barretos, and 472,712 corresponding cases and 194,705 deaths in São Paulo. A clear SES-cancer gradient was seen in São Paulo, with rates varying from 188.4 to 333.1 in low to high SES areas, respectively. There was a lesser social gradient for mortality, with rates in low to high SES areas ranging from 86.4 to 98.0 in Barretos, and from 99.2 to 100.1 in São Paulo. The magnitude of the incidence rates rose markedly with increasing SES in São Paulo city for colorectal, lung, female breast, and prostate cancer. Conversely, both cervical cancer incidence and mortality rose with lower levels of SES in both regions. A clear SES association was seen for cancers of the prostate, female breast, colorectum, and lung for São Paulo. This study offers a better understanding of the cancer incidence and mortality profile according to SES within a highly populated Brazilian state.

Keratinocyte carcinomas, area-level socioeconomic status and geographic remoteness in Tasmania: cross-sectional associations and temporal trends

ObjectiveThis article aims to examine cross-sectional associations and assess temporal trends in keratinocyte carcinoma (KC) incidence by area-level socioeconomic status (SES) and geographic remoteness in Tasmania, Australia. MethodsKCs—basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (SCC)—registered by the Tasmanian Cancer Registry were assigned to area-level SES and remoteness area. Incidence rate ratios (2014–2018) were estimated using Poisson regression. Average annual percentage changes (2001–2018) were estimated using the Joinpoint Regression Program. ResultsBCC incidence increased with increasing area-level advantage (p value for trend <0.001), but no trend was found for SCC. SCC incidence was higher in rural than urban areas (p value <0.001), and BCC incidence was slightly lower in rural than urban areas for males (p value = 0.026), but not for females (p value = 0.381). BCC and SCC incidence increased between 2001 and the mid-2010s, when it peaked across most areas. ConclusionsAssociations were found between BCC and higher area-level SES, and between SCC and geographic remoteness. The findings suggest differences in sun exposure behaviours, skin cancer awareness and access to services, or ascertainment bias. Implications for public healthEfforts to control and deliver KC services in Tasmania should consider targeting populations with specific area-level characteristics.

Long-term exposure to air pollution and risk of SARS-CoV-2 infection and COVID-19 hospitalisation or death: Danish nationwide cohort study.

Early ecological studies have suggested links between air pollution and risk of coronavirus disease 2019 (COVID-19), but evidence from individual-level cohort studies is still sparse. We examined whether long-term exposure to air pollution is associated with risk of COVID-19 and who is most susceptible. We followed 3 721 810 Danish residents aged ≥30 years on 1 March 2020 in the National COVID-19 Surveillance System until the date of first positive test (incidence), COVID-19 hospitalisation or death until 26 April 2021. We estimated residential annual mean particulate matter with diameter ≤2.5 μm (PM2.5), nitrogen dioxide (NO2), black carbon (BC) and ozone (O3) in 2019 by the Danish DEHM/UBM model, and used Cox proportional hazards regression models to estimate the associations of air pollutants with COVID-19 outcomes, adjusting for age, sex, individual- and area-level socioeconomic status, and population density. 138 742 individuals were infected, 11 270 were hospitalised and 2557 died from COVID-19 during 14 months. We detected associations of PM2.5 (per 0.53 μg·m-3) and NO2 (per 3.59 μg·m-3) with COVID-19 incidence (hazard ratio (HR) 1.10 (95% CI 1.05-1.14) and HR 1.18 (95% CI 1.14-1.23), respectively), hospitalisations (HR 1.09 (95% CI 1.01-1.17) and HR 1.19 (95% CI 1.12-1.27), respectively) and death (HR 1.23 (95% CI 1.04-1.44) and HR 1.18 (95% CI 1.03-1.34), respectively), which were strongest in the lowest socioeconomic groups and among patients with chronic respiratory, cardiometabolic and neurodegenerative diseases. We found positive associations with BC and negative associations with O3. Long-term exposure to air pollution may contribute to increased risk of contracting severe acute respiratory syndrome coronavirus 2 infection as well as developing severe COVID-19 disease requiring hospitalisation or resulting in death.

OUTC-08. IMPLEMENTING SOCIAL DETERMINANT OF HEALTH DATA COLLECTION FOR PEDIATRIC, ADOLESCENT AND YOUNG ADULT NEURO-ONCOLOGY PATIENTS IN THE CLINICAL TRIAL CONSORTIA SETTING: PROGRESS AND CHALLENGES

Abstract Adverse social determinants of health (SDoH) are associated with decreased survival and increased long-term complications amongst pediatric and adolescent and young adult (AYA) neuro-oncology patients. These outcome disparities are in part due to inferior access to clinical trials and comprehensive, multidisciplinary care. SDoH including food insecurity, housing instability, inability to pay for utilities, and personal safety issues have been shown to negatively impact therapy adherence and exacerbate survival disparities. As such, efforts to improve health equity must include evaluating and addressing SDoH at diagnosis. Existing literature has been limited by a reliance on proxy measures of adverse SDOH such as neighborhood or census area-level socioeconomic status data, which poorly reflect individual circumstances. There is a complex interplay between neighborhood and personal socioeconomic status that has not been extensively studied and is poorly understood. In addition, socioeconomic status is only one component of SDoH. No validated tool currently exists to assess SDoH amongst pediatric and AYA cancer patients. It is imperative that multicenter clinical trials collect SDoH data to inform both trial design and interpretation of results. These data will be important to understanding and identifying patterns in tumor and toxicity incidence, as well as understanding the burden on families in adhering to trial therapies. Based on our previous work, we will present the importance of incorporating SDoH data collection within the clinical trial consortia setting. In addition, we will review the development of a comprehensive SDoH questionnaire and discuss facilitators and barriers to the incorporation of SDoH questionnaires into multicenter clinical trials and offer solutions based on our experience.

Clinical value of timely targeted therapy (TT) for patients with advanced non-small cell lung cancer (aNSCLC) with actionable driver oncogenes (ADO).

6507 Background: Recent real-world studies observed that some aNSCLC pts with ADO initiated non-targeted therapy (non-TT) before biomarker test results became available. This study assesses the clinical impact of the timing of first line (1L) TT in aNSCLC pts with ADO. Methods: In a retrospective analysis of the nationwide Flatiron Health electronic health record-derived de-identified database, pts aged ≥18 years, diagnosed (Dx) with aNSCLC between 1/1/2015-10/18/2022, had ADO (ALK, BRAF, EGFR, RET, MET, ROS-1, or NTRK) based on biomarker testing ≤ 90 days of advanced Dx, and received 1L treatment (tx) were included. Cohorts were defined by tx patterns after test result: Cohort 1 received 1L TT ≤ 42 days; Cohort 2 initiated 1L non-TT before or after testing but switched to TT ≤ 42 days; Cohort 3 initiated non-TT before or after testing and did not switch to TT ≤ 42 days. Pts were followed from test results + 42 days until 11/30/2022 or death, whichever earliest. Multivariate Cox regression evaluated real-world progression-free survival (rwPFS) and overall survival (OS) between cohorts. Results: A total of 5156 aNSCLC pts with ADO were included: 79% were treated in the community setting and 56% received NGS testing. Most common ADO were EGFR and ALK for both Cohort 1 (78% and 13%) and Cohort 2 (67% and 24%); EGFR (39%) and BRAF (35%) for Cohort 3. Cohort 3 included more rare mutations (MET, NTRK, RET). Statistically significant differences were observed in gender, race/ethnicity, practice type, and area-level socioeconomic status across all cohorts. There was no significant difference in outcomes observed between Cohort 2 and 1, but significantly inferior outcomes in Cohort 3 vs 1. Conclusions: Our findings demonstrated better outcomes with upfront 1L TT vs non-TT in aNSCLC pts with ADO. The comparable outcomes between pts who received 1L TT after test result and pts who switched to TT ≤ 42 days of test result available underscore the importance of timely tx decisions based on ADO detection in lieu of tx-switch at progression. Opportunities remain to improve utilization of NGS to identify all ADO upfront to inform the appropriate 1L TT when indicated. [Table: see text]

Trial eligibility criteria (EC) and diversity among patients with advanced non small cell lung cancer (advNSCLC).

1566 Background: FDA guidance encourages using real world data in developing diversity plans for clinical trials. Diversity plans may incorporate more inclusive (or expanded) EC, which may increase enrollment of minoritized populations. Whether broadened EC affect the diversity of eligible participants is unknown. Methods: Using the nationwide Flatiron Health electronic health record-derived deidentified database, we included patients with advNSCLC from 1/1/17-11/30/22 with a line of therapy (LOT) (N=61596). EC were defined by FDA, NCI/CTEP, and ASCO/FoCR standards, and included ECOG, ALT, AST, ALP, bilirubin, eGFR, CrCl, HGB, ANC &amp; PLT -90 to +7 days from first LOT. Claims-linkage identified brain mets (BM), congestive heart failure (CHF), hepatitis C (HCV) &amp; B (HBV), HIV and myocardial infarction (MI) within 6 months of first LOT. Logistic regression estimated odds ratios (OR) for exclusion by criterion associated with gender, age, race/ethnicity and area-level socioeconomic status (SES). Adjusting for clinical characteristics, Cox regression estimated hazard ratios (HR) for real world overall survival (rwOS). Results: Female patients (vs male patients) had greater odds of exclusion by CrCl (OR 2.9), eGFR (OR 1.27) &amp; BM (OR 1.30). Compared to non-Latinx (NL) White patients, NL Black patients had greater odds of exclusion by ECOG (OR 1.17), CrCl (OR 1.33), eGFR (OR 1.61), HGB (OR 2.2), ANC (OR 1.71), HIV (OR 5.31), CHF (OR 1.31), HBV (OR 2.29) and HCV (OR 2.73); NL Asian patients by ALT (OR 1.64), ALP (OR 1.71), CrCl (OR 1.63), BM (OR 1.45) and HBV (OR 26.2); and Latinx patients by ALP (OR 1.56), HIV (OR 2.23) and HCV (OR 1.47). Compared to younger patients (18-49), older patients (75-84) had greater odds of exclusion by ECOG (OR 2.12), bilirubin (OR 1.53), CrCl (OR 41.9), eGFR (OR 9.54), CHF (OR 4.9) and MI (OR 4.7). Patients with the lowest (vs highest) quintile of SES had greater odds of exclusion by ECOG (OR 1.29) and HGB (OR 1.52). Among patients with complete data on all non-claims criteria (N=22117), the impact of expanding EC on diversity is shown, except SES which was similar. Compared to standard EC, the group with expanded EC had lower rwOS (adj HR 1.32; 95% CI 1.28-1.37). Conclusions: Expanding EC has the potential to increase the proportion and absolute number of Black, older, and female patients in advNSCLC trials. The resulting more diverse eligible population may have different clinical outcomes compared to a cohort defined by more restrictive EC. Future work will explore generalizability of findings to other clinical contexts.[Table: see text]

Area-level and individual-level socio-economic differences in health-related quality of life trajectories: Results from a 10-year longitudinal stroke study

BackgroundWe examined area-level (aSES) and individual-level (iSES) socio-economic status on trajectories of HRQoL to 10 years following stroke. MethodsParticipants with strokes between 1/5/1996 and 30/4/1999 completed the Assessment of Quality of Life instrument (AQoL, range: -0.04 [worse than death] to 0 [death] to 1 [full health]) at ≥one of 3month, 6-month, 1-year, 2-year, 3-year, 4-year, 5-year, 7-year and 10-year interviews after stroke. Sociodemographic and health information were collected at baseline. We derived aSES from postcode using the Australian Socio-Economic Indexes For Area (2006) (categories: high, medium, low), and iSES from lifetime occupation (categories: non-manual, manual). Multivariable linear mixed effects modelling was used to estimate trajectories of HRQoL over 10 years, by aSES and iSES, adjusting for age, sex, cardiovascular disease, smoking, diabetes, stroke severity, stroke type, and the time influence on age and health conditions. ResultsOf 1,686 participants enrolled, we excluded 239 with ‘possible’ stroke and 284 with missing iSES. Among the remaining 1,163 participants, 1,123 (96.6%) had AQoL assessed at ≥3 timepoints. In multivariable analysis, over time, people in the medium aSES group had mean 0.02 (95% CI -0.06, 0.02) greater reduction in AQoL score, and people in the low aSES group had mean 0.04 (95% CI, -0.07, -0.001) greater reduction, than those in the high aSES group. Manual workers had an average 0.04 (95% CI, -0.07, -0.01) greater reduction in AQoL score over time than non-manual workers. ConclusionsOver time, HRQoL declines in all people with stroke, declining most rapidly in lower SES groups.

Socioeconomic disparities in immunotherapy use among advanced-stage non-small cell lung cancer patients: analysis of the National Cancer Database

Socioeconomic and racial disparities exist in access to care among patients with non-small cell lung cancer (NSCLC) in the United States. Immunotherapy is a widely established treatment modality for patients with advanced-stage NSCLC (aNSCLC). We examined associations of area-level socioeconomic status with receipt of immunotherapy for aNSCLC patients by race/ethnicity and cancer facility type (academic and non-academic). We used the National Cancer Database (2015–2016), and included patients aged 40–89 years who were diagnosed with stage III-IV NSCLC. Area-level income was defined as the median household income in the patient’s zip code, and area-level education was defined as the proportion of adults aged ≥ 25 years in the patient’s zip code without a high school degree. We calculated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) using multi-level multivariable logistic regression. Among 100,298 aNSCLC patients, lower area-level education and income were associated with lower odds of immunotherapy treatment (education: aOR 0.71; 95% CI 0.65, 0.76 and income: aOR 0.71; 95% CI 0.66, 0.77). These associations persisted for NH-White patients. However, among NH-Black patients, we only observed an association with lower education (aOR 0.74; 95% CI 0.57, 0.97). Across all cancer facility types, lower education and income were associated with lower immunotherapy receipt among NH-White patients. However, among NH-Black patients, this association only persisted with education for patients treated at non-academic facilities (aOR 0.70; 95% CI 0.49, 0.99). In conclusion, aNSCLC patients residing in areas of lower educational and economic wealth were less likely to receive immunotherapy.

Socioeconomic Inequality in Hearing Impairment Among Working-Age Australians: Evidence From a Cross-Sectional and Longitudinal Analyses.

The objective of this study was to analyze the spatial and temporal association between socioeconomic gradient in hearing impairment among working-age Australians. We modeled the cross-sectional and longitudinal associations between individual- and area-level socioeconomic status (SES) and hearing impairment among working-age Australians using longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey for 10,719 working-age adults aged between 15 and 64 years surveyed between 2008 and 2018. Associations between self-reported hearing impairment and education, income, employment status, and area-level SES were estimated using a multivariate logistic regression model and Cox proportional hazards regression, controlling for age, sex, and a range of other sociodemographic factors. Among 10,719 participants, the prevalence of hearing impairment was higher among individuals with lower income, occupational status and socioeconomic disadvantage. The odds ratio (OR) of those with the lowest income quintile versus highest income quintile (OR = 2.10, 95% confidence interval [CI] = 1.40 to 3.14); for blue-collar occupation versus white-collar (OR = 1.92, 95% CI = 1.39 to 2.66) and most disadvantaged area quintile versus most advantaged area quintile (OR = 1.76, 95% CI = 1.10 to 2.83) were associated with higher odds of prevalence of hearing impairment. For the 10,046 participants without hearing loss at baseline, income quintile 1 versus quintile 5 (hazard ratio [HR] = 1.44, 95% CI = 1.33 to 1.56), ≤ year 11 versus ≥ bachelor's degree (HR = 2.15, 95% CI = 1.98-2.34) blue-collar occupation versus white collar (HR = 1.15, 95% CI = 1.07 to 1.25) and most disadvantaged area quintile versus most advantaged quintile (HR = 1.49, 95% CI = 1.37 to 1.63) was positively associated with incident hearing impairment. Lower individual-level and area-level SES was associated with an increased risk of prevalence and incidence of hearing impairment among working-age Australians. These findings are particularly concerning since working-age Australians are mostly not eligible for socially subsidized hearing-related health care in Australia. This lack of access to affordable hearing services could exacerbate the negative consequences of hearing impairment and increase social inequality.

Long-term exposure to ultrafine particles and natural and cause-specific mortality

BackgroundHealth implications of long-term exposure to ubiquitously present ultrafine particles (UFP) are uncertain. The aim of this study was to investigate the associations between long-term UFP exposure and natural and cause-specific mortality (including cardiovascular disease (CVD), respiratory disease, and lung cancer) in the Netherlands. MethodsA Dutch national cohort of 10.8 million adults aged ≥ 30 years was followed from 2013 until 2019. Annual average UFP concentrations were estimated at the home address at baseline, using land-use regression models based on a nationwide mobile monitoring campaign performed at the midpoint of the follow-up period. Cox proportional hazard models were applied, adjusting for individual and area-level socio-economic status covariates. Two-pollutant models with the major regulated pollutants nitrogen dioxide (NO2) and fine particles (PM2.5 and PM10), and the health relevant combustion aerosol pollutant (elemental carbon (EC)) were assessed based on dispersion modelling. ResultsA total of 945,615 natural deaths occurred during 71,008,209 person-years of follow-up. The correlation of UFP concentration with other pollutants ranged from moderate (0.59 (PM2.5)) to high (0.81 (NO2)). We found a significant association between annual average UFP exposure and natural mortality [HR 1.012 (95 % CI 1.010–1.015), per interquartile range (IQR) (2723 particles/cm3) increment]. Associations were stronger for respiratory disease mortality [HR 1.022 (1.013–1.032)] and lung cancer mortality [HR 1.038 (1.028–1.048)] and weaker for CVD mortality [HR 1.005 (1.000–1.011)]. The associations of UFP with natural and lung cancer mortality attenuated but remained significant in all two-pollutant models, whereas the associations with CVD and respiratory mortality attenuated to the null. ConclusionLong-term UFP exposure was associated with natural and lung cancer mortality among adults independently from other regulated air pollutants.

Neighborhood socioeconomic status and cardiometabolic risk: mediating roles of domain-specific physical activities and sedentary behaviors

PurposeWe examined the potential mediating roles of domain-specific physical activities and sedentary behaviors in the relationship between area-level socioeconomic status (SES) and cardiometabolic risk. MethodsData were from the 2011/2012 Australian Diabetes, Obesity and Lifestyle study (n = 3431). The outcome was a clustered cardiometabolic risk (CCR) score, and the exposure was suburb-level SES. Potential mediators were domain-specific physical activities and sedentary behaviors. Multilevel linear regression models examined associations between SES and potential mediators (α) and between mediators and CCR (β). Mediation was assessed using the joint-significance test. ResultsHigher SES was associated with a lower CCR score. Lower SES was associated with less frequent walking for transport, lower vigorous-intensity recreational physical activity, and higher TV time, which were associated with higher CCR scores. However, higher SES was associated with longer transport-related sitting time (all modes and in cars), which were associated with higher CCR scores. ConclusionsThe SES-cardiometabolic risk relationship may be partially explained by walking for transport, vigorous-intensity recreational physical activity, and TV viewing. These findings, which require corroboration from prospective evidence and clarification of the roles of transport-related sitting and occupational physical activity, can inform initiatives addressing socioeconomic inequalities in cardiometabolic health.

Association between individual, household, and area-level socioeconomic status indicators and sensorineural hearing loss in adults in southwest Iran: a population-based study.

Hearing loss is the fourth most common chronic disease, but studies on the relationship between hearing loss and socioeconomic factors are limited. We aimed to examine the association between hearing loss and socioeconomic factors among 35-70 year adults in southwest Iran. This population-based cross-sectional study was conducted in the baseline of Hoveyzeh cohort study in adults aged 35-70 in southwest Iran between 2017 and 2021. Information on socioeconomic factors, demographic characteristics, comorbidities, family history of hearing loss, and noise exposure was collected. We assessed the relationship between three levels of socioeconomic factors (individual, household, and area level) with sensorineural hearing loss (SNHL). Multiple logistic regression was used to adjust the potential confounders. Among a total of 1,365 assessed participants, 485 patients were diagnosed as having hearing loss, and the other 880 individuals were diagnosed without hearing loss, which is considered the case and the control group, respectively. At the individual level of socioeconomic, the odds of having hearing loss in the participants with high school education and diploma, [OR = 0.51 (95%CI:0.28-0.92)], and the individuals with university education [OR = 0.44 (95%CI:0.22-0.87)] were significantly lower than the illiterate participants. At the household socioeconomic level, the odds of having hearing loss were lower for those with poor [OR = 0.63 (95%CI:0.41-0.97)] and moderate [OR = 0.62 (95%CI:0.41-0.94)] wealth status vs. those with the poorest wealth status. In the area level socioeconomic, although the odds of hearing loss in the residents of affluent areas were slightly lower than the residents of deprived areas, there was no significant difference among the groups. The individuals with hearing loss may have insufficient education and income.

Powerful promotions: An investigation of the teen-directed marketing power of outdoor food advertisements located near schools in Australia.

Adolescents are heavily exposed to unhealthy outdoor food advertisements near schools, however, the marketing power of these advertisements among adolescents has not yet been explored. This study aimed to investigate the teen-directed marketing features present and quantify the overall marketing power of outdoor food advertisements located near schools to explore any differences by content (ie, alcohol, discretionary, core and miscellaneous foods) school type (ie, primary, secondary, K-12) and area-level socio-economic status (SES; ie, low vs high). This cross-sectional study audited every outdoor food advertisement (n = 1518) within 500m of 64 randomly selected schools in Perth, Western Australia, using a teen-informed coding tool to score the marketing power of each advertisement. Outdoor alcohol advertisements around schools had the highest average marketing power score and number of advertising features present. Outdoor advertisements for alcohol and discretionary foods scored significantly higher in marketing power than core food advertisements (P < .001). Outdoor alcohol advertisements around secondary schools scored significantly higher in marketing power than around primary and K-12 schools (P < .001); and outdoor advertisements for discretionary foods in low SES areas scored significantly higher in marketing power than those in high SES areas (P < .001). This study found outdoor advertisements for unhealthy products, such as alcohol and discretionary foods, were more powerful than advertisements for core foods around schools. SO WHAT?: These findings strengthen the need for policies which restrict outdoor advertisements for non-core foods near schools, to reduce adolescents' exposure to powerful alcohol and discretionary food advertisements.

Long-term exposure to traffic-related air pollution and non-accidental mortality: A systematic review and meta-analysis

BackgroundThe health effects of traffic-related air pollution (TRAP) continue to be of important public health interest across the globe. Following its 2010 review, the Health Effects Institute appointed a new expert Panel to systematically evaluate the epidemiological evidence regarding the associations between long-term exposure to TRAP and selected health outcomes. This paper describes the main findings of the systematic review on non-accidental mortality. MethodsThe Panel used a systematic approach to conduct the review. An extensive search was conducted of literature published between 1980 and 2019. A new exposure framework was developed to determine whether a study was sufficiently specific to TRAP, which included studies beyond the near-roadway environment. We performed random-effects meta-analysis when at least three estimates were available of an association between a specific exposure and outcome. We evaluated confidence in the evidence using a modified Office of Health Assessment and Translation (OHAT) approach, supplemented with a broader narrative synthesis. ResultsThirty-six cohort studies were included. Virtually all studies adjusted for a large number of individual and area-level covariates—including smoking, body mass index, and individual and area-level socioeconomic status—and were judged at a low or moderate risk for bias. Most studies were conducted in North America and Europe, and a few were based in Asia and Australia. The meta-analytic summary estimates for nitrogen dioxide, elemental carbon and fine particulate matter—pollutants with more than 10 studies—were 1.04 (95% CI 1.01, 1.06), 1.02 (1.00, 1.04) and 1.03 (1.01, 1.05) per 10, 1 and 5 µg/m3, respectively. Effect estimates are interpreted as the relative risk of mortality when the exposure differs with the selected increment. The confidence in the evidence for these pollutants was judged as high, because of upgrades for monotonic exposure–response and consistency across populations. The consistent findings across geographical regions, exposure assessment methods and confounder adjustment resulted in a high confidence rating using a narrative approach as well. ConclusionsThe overall confidence in the evidence for a positive association between long-term exposure to TRAP and non-accidental mortality was high.

Insurance Type and Area Deprivation Are Associated With Worse Overall Mortality for Patients With Muscle-invasive Bladder Cancer

To examine the association of area-level socioeconomic status, rural-urban residence, and type of insurance with overall and cancer-specific mortality among patients with muscle-invasive bladder cancer. Using the Pennsylvania Cancer Registry, which collects demographic, insurance, and clinical information on every patient with cancer within the state, we identified all patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2016 based on clinical and pathologic staging. We used the Area Deprivation Index (ADI) as a surrogate for socioeconomic status and Rural-Urban Commuting Area codes to classify urban, large town, and rural communities. ADI was reported in quartiles, with 4 representing the lowest socioeconomic status. We fit multivariable logistic regression and Cox models to assess the relationship of these social determinants with overall and cancer-specific survival adjusting for age, sex, race, stage, treatment, rural-urban classification, insurance and ADI. We identified 2597 patients with non-metastatic muscle-invasive bladder cancer. On multivariable analysis, Medicare (hazards ratio [HR] 1.15), Medicaid (HR 1.38), ADI 3 (HR 1.16) and ADI 4 (HR 1.21) were independent predictors of greater overall mortality (all P < 0.05). Female sex and receipt of non-standard treatment were associated with increased overall mortality and bladder cancer-specific mortality. There was no significant difference in both overall and cancer-specific survival between patients who were non-Hispanic White compared to non-White or between those from urban areas, large towns, or rural locations. Lower socioeconomic status and Medicare and Medicaid insurance were associated with a greater risk of overall mortality while rural residence was not a significant factor. Implementation of public health programs may help reduce the gap in mortality for low SES at-risk populations.

Area-level socioeconomic status is positively correlated with glioblastoma incidence and prognosis in the United States.

In the United States, an individual's access to resources, insurance status, and wealth are critical social determinants that affect both the risk and outcomes of many diseases. One disease for which the correlation with socioeconomic status (SES) is less well-characterized is glioblastoma (GBM), a devastating brain malignancy. The aim of this study was to review the current literature characterizing the relationship between area-level SES and both GBM incidence and prognosis in the United States. A query of multiple databases was performed to identify the existing data on SES and GBM incidence or prognosis. Papers were filtered by relevant terms and topics. A narrative review was then constructed to summarize the current body of knowledge on this topic. We obtained a total of three papers that analyze SES and GBM incidence, which all report a positive correlation between area-level SES and GBM incidence. In addition, we found 14 papers that focus on SES and GBM prognosis, either overall survival or GBM-specific survival. Those studies that analyze data from greater than 1,530 patients report a positive correlation between area-level SES and individual prognosis, while those with smaller study populations report no significant relationship. Our report underlines the strong association between SES and GBM incidence and highlights the need for large study populations to assess SES and GBM prognosis to ideally guide interventions that improve outcomes. Further studies are needed to determine underlying socio-economic stresses on GBM risk and outcomes to identify opportunities for intervention.

Correlates of Physical Activity in Children from Families Speaking Non-official Languages at Home: a Multi-site Canadian Study.

Children from families speaking a non-official language at home may be particularly at risk for low physical activity (PA), underscoring a need to investigate correlates of PA in this subpopulation. We recruited 478 children in 37 schools stratified by area-level socioeconomic status (SES) and type of urbanization within three regions of Canada. Steps/day were measured using SC-StepRx pedometers. We assessed potential social-ecological correlates with child and parent surveys. We used gender-stratified linear mixed models to examine the correlates of steps/day. Outdoor time was the strongest correlate of boys' and girls' PA. Lower area-level SES was associated with less PA among boys, but outdoor time attenuated this difference. The strength of association between outdoor time and PA decreased with age in boys and increased with age in girls. Outdoor time was the most consistent correlate of PA. Future interventions should promote outdoor time and address socioeconomic disparities.

Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status

Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer. To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status. This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023. Health inusurance status (private or Medicare insurance vs Medicaid or uninsured). The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status. A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women. This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

Individual and area-level socioeconomic correlates of hypertension prevalence, awareness, treatment, and control in uMgungundlovu, KwaZulu-Natal, South Africa

BackgroundHypertension is the second leading risk factor for death in South Africa, and rates have steadily increased since the end of Apartheid. Research on the determinants of hypertension in South Africa has received considerable attention due to South Africa’s rapid urbanization and epidemiological transition. However, scant work has been conducted to investigate how various segments of the Black South African population experience this transition. Identifying the correlates of hypertension in this population is critical to the development of policies and targeted interventions to strengthen equitable public health efforts.MethodsThis analysis explores the relationship between individual and area-level socioeconomic status and hypertension prevalence, awareness, treatment, and control within a sample of 7,303 Black South Africans in three municipalities of the uMgungundlovu district in KwaZulu-Natal province: the Msunduzi, uMshwathi, and Mkhambathini. Cross-sectional data were collected on participants from February 2017 to February 2018. Individual-level socioeconomic status was measured by employment status and educational attainment. Ward-level area deprivation was operationalized by the most recent (2011 and 2001) South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and diabetes diagnosis.ResultsThe prevalence of hypertension in the sample was 44.4% (n = 3,240). Of those, 2,324 were aware of their diagnosis, 1,928 were receiving treatment, and 1,051 had their hypertension controlled. Educational attainment was negatively associated with hypertension prevalence and positively associated with its control. Employment status was negatively associated with hypertension control. Black South Africans living in more deprived wards had higher odds of being hypertensive and lower odds of having their hypertension controlled. Those residing in wards that became more deprived from 2001 to 2011 had higher odds of being aware of their hypertension, yet lower odds of receiving treatment for it.ConclusionsResults from this study can assist policymakers and practitioners in identifying groups within the Black South African population that should be prioritized for public health interventions. Black South Africans who have and continue to face barriers to care, including those with low educational attainment or living in deprived wards had worse hypertension outcomes. Potential interventions include community-based programs that deliver medication to households, workplaces, or community centers.