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Liver transplantation (LT) is the final step in a complex care cascade. Little is known about how race, gender, rural versus urban residence, or neighborhood socioeconomic indicators impact a patient's likelihood of LT waitlisting or risk of death during LT evaluation. We performed a retrospective cohort study of adults referred for LT to the Indiana University Academic Medical Center from 2011 to 2018. Neighborhood socioeconomic status indicators were obtained by linking patients' addresses to their census tract defined in the 2017 American Community Survey. Descriptive statistics were used to describe completion of steps in the LT evaluation cascade. Multivariable analyses were performed to assess the factors associated with waitlisting and death during LT evaluation. There were 3454 patients referred for LT during the study period; 25.3% of those referred were waitlisted for LT. There was no difference seen in the proportion of patients from vulnerable populations who progressed to the steps of financial approval or evaluation start. There were differences in waitlisting by insurance type (22.6% of Medicaid vs. 34.3% of those who were privately insured; p 0.01) and neighborhood poverty (quartile 1 29.6% vs. quartile 4 20.4%; p 0.01). On multivariable analysis, neighborhood poverty was independently associated with waitlisting (odds ratio 0.56, 95% confidence interval [CI] 0.38-0.82) and death during LT evaluation (hazard ratio 1.49, 95% CI 1.09-2.09). Patients from high-poverty neighborhoods are at risk of failing to be waitlisted and death during LT evaluation.

The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors.The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics.Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p0.05).Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate.Risk, III.

ObjectiveTo investigate the relationship between late-life duration of poverty exposure and cognitive function and decline among older adults in China.MethodsData were from 3,209 participants ≥64 years of age in the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Duration of poverty, defined according to urban and rural regional standards from the China Statistical Yearbook, was assessed according to annual household income from 2005 to 2011 (never in poverty; one-third of the period in poverty; two-thirds or more of the period in poverty). Cognitive function was measured by the Chinese Mini-Mental State Examination (CMMSE) from 2011 to 2018. We used attrition-weighted, multivariable mixed-effects Tobit regression to examine the association of duration of poverty with cognitive function and rate of decline.ResultsA total of 1,162 individuals (36.21%) were never in poverty over the period from 2005 to 2011; 1,172 (36.52%) were in poverty one-third of the period; and 875 (27.27%) were in poverty two-thirds or more of the period. A longer poverty duration was associated with lower subsequent CMMSE scores with a dose-response relationship (one-third vs never in poverty: β = −0.98; 95% confidence interval −1.61 to −0.35; two-thirds or more vs never in poverty: β = −1.55; 95% confidence interval −2.29 to −0.81). However, a longer duration of poverty was associated with a slower rate of CMMSE score decline over time from 2011 to 2018.ConclusionThese findings provide valuable evidence for the role of cumulative late-life poverty in relation to cognitive health among older adults in a rapidly urbanizing and aging middle-income country. Our findings may support a compensation hypothesis for cognitive reserve in this setting.

Poverty has detrimental effects on health outcomes. Doctorally prepared nurse practitioners are in a position to promote health for patients and communities experiencing poverty. To do so, they must be aware of their own attitudes and to have empathy toward the condition of poverty. Specialized poverty simulations have been successfully used to improve attitudes toward poverty among prelicensure nursing students, but there is a paucity of evidence exploring the effects of poverty simulations among Students in a Doctor of Nurse Practice (DNP) program. The purpose of this study was to evaluate the impact of a poverty simulation for students enrolled in a DNP program on their attitudes toward poverty. A quasi-experimental, pre-test and post-test survey design was used in this curriculum improvement project. A total of 29 DNP students participated in a 1-time, 4-hour Community Action Poverty Simulation© (CAPS). The simulations presented various challenges faced during 1 month of living in poverty. The Attitudes toward Poverty Scale-Short Form (ATPS-SF) was used to measure attitudes toward poverty both before and after the CAPS© experience. Descriptive statistics and paired t-tests were used to describe the participant group and measure the impact of the simulation on attitudes toward poverty. Attitudes toward poverty improved overall on all dimensions of the ATPS-SF after the CAPS© experience as compared to the pre-test, with particular improvement regarding stigmas related to poverty. Statistically significant improvements were detected on four items, and the overall favorable shift in attitudes presents clinically significant results. This poverty simulation experience should be considered for adoption into DNP curricula.

Pain disparities based on race, sex, age, and socioeconomic status have been well documented. This study aimed to examine interactions among these sociodemographic factors on self-reported bodily pain in an urban community sample to assess whether membership in multiple at-risk groups confers greater risk for pain independent of depressive symptomatology. Participants (N = 1173) were enrolled in the epidemiological Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, and reported experiences of pain in various body sites. Logistic regression was used to examine independent and interactive relations of sociodemographic factors on the likelihood of reporting pain in one or more sites. A significant three-way interaction was found for race, sex, and poverty status (odds ratio [OR] = 6.04, 95% confidence interval [CI] [1.26-28.97], P = 0.025). Specifically, among Whites living in poverty, women were more likely to report pain than men (P = 0.043), suggesting a double disadvantage of being both female and living in poverty. Among those above the poverty line, African American (AA) men were less likely to report pain than White men (P = 0.024) and AA women (P = 0.019), potentially due to greater stoicism or coping skills and sources of resilience. Consistent with prior research, significant main effects revealed that older age (OR = 2.16, 95% CI [1.28-3.64], P = 0.004) and higher depressive symptoms (OR = 1.03, 95% CI [1.02-1.04], P < 0.001) were associated independently with increased likelihood of reporting pain. This study demonstrates that in an urban population, intersecting sociodemographic factors create unique social identities that impact pain, and emphasizes the need for identification of relevant mediational pathways.

OBJECTIVES To study the impact of sociodemographic factors on length of stay (LOS) for infants with neonatal opioid withdrawal syndrome (NOWS) secondary to fetal opioid exposure. METHODS In this retrospective cohort study, we included term infants with NOWS, excluding those with other significant medical issues. Comprehensive clinical and sociodemographic data were collected. Multivariate regression modeling was used to identify factors which contributed to excess LOS, which was defined as the number of days beyond the standard monitoring and/or treatment protocol. RESULTS In all, 129 infants were identified; mean gestational age of 37.9 ± 1.3 weeks and mean body weight of 2880 ± 496 g. Among them, 68% of infants were exposed to opioids; 27% were exposed to methadone; and 67% required pharmacologic treatment. The degree of poverty was assessed using the Area Deprivation Index (ADI) based on the mother's address at the time of birth. Median LOS for treated infants was 23 days versus 8 days for those who did not need pharmacologic treatment. The median excess LOS was 4 days (range 0-24).Excess hospital days were strongly correlated with degree of deprivation in the mother's community (r = 0.55, P

Background Poverty is a harsh reality for more than 40 million Americans, which can lead to detrimental health outcomes. Problem Considering health professionals encounter clients of low-income status, increasing awareness and empathy toward this population is essential. Approach This article describes a novel approach to conducting poverty simulations by using community volunteers that are currently living or have recently lived in poverty, lending to a more authentic experience for students. The community volunteers acted as resource workers during the simulation. Outcomes Five lessons were learned as part of this authentic approach including the importance of orientation, consistent volunteer recruitment, volunteer appreciation, simulation role ownership, and importance of incentives. Conclusion This approach is an effective initial step in increasing awareness and empathy among health care profession students toward individuals living in poverty. Use of community volunteers with personal experience with poverty enhances the realism of this experience for students.

OBJECTIVE: In an effort to promote the health and developmental outcomes of children born into poverty, the Centers for Disease Control and Prevention (CDC) conceptualized and designed the Legacy for Children™ (Legacy) public health prevention model. This article examines the impact of Legacy on children’s cognitive and language development (intelligence quotient [IQ], achievement, language skills, and early reading skills) using both standardized assessments and parent-reported indictors through third grade. METHODS: Data were collected from 2001 to 2014 from 541 mother-child dyads who were recruited into the 2 concurrent randomized controlled trials of Legacy in Miami and Los Angels. Cognitive and/or language outcomes of children were assessed annually from age 2 to 5 years as well as during a follow-up visit in the third grade. RESULTS: Children experiencing Legacy at the Los Angeles site had significantly higher IQ and achievement scores at 2 and 6 years postintervention, equivalent to approximately one-third of an SD (4 IQ points). IQ results persisted over time, and the difference between intervention and comparison groups on achievement scores widened. There were no significant differences in cognitive outcomes in the Miami sample. There were no significant differences in language outcomes for either site. CONCLUSION: Legacy shows evidence of effectiveness as an intervention to prevent cognitive delays among children living in poverty. The mixed findings across sites may not only reflect the impact of heterogeneous risk profiles noted by other intervention research programs but also warrant additional study.

Background Preterm birth, defined as birth before the completion of 37 weeks of gestation, is a multifactorial global epidemic with psychosocial, economic, and physical ramifications affecting the child, family, and community at large. Toxic stress-the results of exposure to adverse childhood experiences-results in changes to brain structure and function that negatively affects future health. Objectives The aim of this study was to apply the eco-bio-developmental (EBD) model of poverty and preterm birth to the cross-sectional data of the 2016 National Survey of Children's Health to evaluate the associations between poverty, toxic stress, and prematurity on neurodevelopmental and educational outcomes. Methods A subset of data representing children ages 6-11 years old (n = 15,010) from the 2016 National Survey of Children's Health was used for multivariate analysis of demographic variables and neurodevelopmental and educational outcome variables. Pearson's chi-square, logistic regression, and interaction effects explored the relationships between prematurity, toxic stress, and poverty. Results Children in this sample born preterm had a higher incidence of toxic stress, poverty, developmental delay, learning disability, intellectual disability, speech/language disorders, attention-deficit disorder (ADD)/attention-deficit/hyperactivity disorder (ADHD), autism, and special education/early intervention plans. The combination of poverty, toxic stress, and preterm birth significantly increased the risk of these conditions. After accounting for gender, insurance coverage, race, and parental education, children in the sample born preterm were more likely to experience developmental delay, intellectual disability, speech/language disorder, learning disability, and ADD/ADHD. Toxic stress increased the incidence of ADD/ADHD and autism in both the preterm and full-term samples. Discussion The negative effect of poverty and toxic stress on children born preterm, as depicted by the eco-bio-developmental model, is supported by this analysis. Healthcare providers are encouraged to address the tripartite vulnerability resulting from prematurity, poverty, and toxic stress.

We aim to investigate the status and influence factors of health risk behaviors among middle school students and explore the relationship between social support, family care, and the health risk behaviors. The study was conducted in 3 middle schools in the Fan county located in the Puyang city. Independent measures were applied to assess adolescent health risk behaviors, perceive social support, and family care. Multiple regression analysis was used to analyze the main factors that affect adolescent health risk behaviors. The total scores of health risk behaviors were 53.87 ± 9.97, and all kinds of health risk behaviors were very common. The highest score was health-compromising (2.45 ± 0.43), and the lowest score was unprotected sex behaviors (1.07 ± 0.28). Multiple regression analysis showed that sex (P.001), grade (P.001), parent relationships (P.001), father's occupation (P = .035), mother's education level (P = .011), social support (P.001), affection (P.001), and growth (P = .003) were the main factors of health risk behaviors, accounting for 25.3%. The health risk behaviors among middle school students in Fan county should attract the attention of education administration, schools, and parent due to the varied influencing factors. Related interventions should be conducted to reduce the severity and frequency of adolescent health risk behaviors and protect the health and growth of adolescents. In order to better analyze the health risk behaviors of middle school students, we will incorporate more influencing factors and carry out further causal analysis in the future.

Aim This article presents results of an exploratory qualitative study examining gains in empathy and social justice beliefs among undergraduate nursing students. Background As undergraduate nursing education provides the foundation for future forensic nurses, developing successful methods to increase beliefs and behaviors of social empathy and social justice among nursing students will have a beneficial effect on the specialty of forensic nursing. As such, a team of nursing researchers explored the effects of a poverty simulation on the social empathy and social justice beliefs held by undergraduate students. Method The research team conducted an exploratory qualitative study of student reflective journals. Using an inductive interpretive process, the researchers performed a content analysis of student responses. Results The researchers identified three constitutive patterns and eight supporting themes as reflected in the students' reflective journals after participation in poverty simulation sessions. Conclusion This research study found that, when nursing students participate in poverty simulation experiences, they gain an increased understanding of the vulnerability and complexities of living in poverty and are motivated to both advocate for patients and become change agents. Application Such increases in social empathy and promotion of social justice will inevitably positively affect their future practice and inform their development as forensic nurses.

Background There is significant geographical variation in heart failure ( HF ) mortality across the United States. County socioeconomic factors that influence these outcomes are unknown. We studied the association between county socioeconomic factors and HF mortality and compared it with coronary heart disease ( CHD ) mortality. Methods and Results This is a cross‐sectional analysis of socioeconomic factors and mortality in HF and CHD across 3135 US counties from 2010 to 2015. County‐level poverty, education, income, unemployment, health insurance status, and cause‐specific mortality rates were collected from the Centers for Disease Control and Prevention and US Census Bureau databases. Poverty had the strongest correlation with both HF and CHD mortality, disproportionately higher for HF ( r =0.48) than CHD ( r =0.24). HF mortality increased by 5.2 deaths/100 000 for each percentage increase in county poverty prevalence in a frequency‐weighted, demographic‐adjusted, multivariate regression model. The greatest attenuation in the poverty regression coefficient (66.4%) was seen after adjustment for prevalence of diabetes mellitus and obesity. Subgroup analysis by census region showed that this relationship was the strongest in the South and weakest in the Northeast (6.1 versus 1.4 deaths/100 000 per 1% increase in county poverty in a demographics‐adjusted model). Conclusions County poverty is the strongest socioeconomic factor associated with HF and CHD mortality, an association that is stronger with HF than with CHD and varied by census region. Over half of the association was explained by differences in the prevalence of diabetes mellitus and obesity across the counties. Health policies targeting improvement in these risk factors may address and possibly minimize health disparities caused by socioeconomic factors.

Race is an important predictor of TKA outcomes in the United States; however, analyses of race can be confounded by socioeconomic factors, which can result in difficulty determining the root cause of disparate outcomes after TKA. We asked: (1) Are race and socioeconomic factors at the individual level associated with patient-reported pain and function 2 years after TKA? (2) What is the interaction between race and community poverty and patient-reported pain and function 2 years after TKA? We identified all patients undergoing TKA enrolled in a hospital-based registry between 2007 and 2011 who provided 2-year outcomes and lived in New York, Connecticut, or New Jersey. Of patients approached to participate in the registry, more than 82% consented and provided baseline data, and of these patients, 72% provided 2-year data. Proportions of patients with complete followup at 2 years were lower among blacks (57%) than whites (74%), among patients with Medicaid insurance (51%) compared with patients without Medicaid insurance (72%), and among patients without a college education (67%) compared with those with a college education (71%). Our final study cohort consisted of 4035 patients, 3841 (95%) of whom were white and 194 (5%) of whom were black. Using geocoding, we linked individual-level registry data to US census tracts data through patient addresses. We constructed a multivariate linear mixed-effect model in multilevel frameworks to assess the interaction between race and census tract poverty on WOMAC pain and function scores 2 years after TKA. We defined a clinically important effect as 10 points on the WOMAC (which is scaled from 1 to 100 points, with higher scores being better). Race, education, patient expectations, and baseline WOMAC scores are all associated with 2-year WOMAC pain and function; however, the effect sizes were small, and below the threshold of clinical importance. Whites and blacks from census tracts with less than 10% poverty have similar levels of pain and function 2 years after TKA (WOMAC pain, 1.01 ± 1.59 points lower for blacks than for whites, p = 0.53; WOMAC function, 2.32 ± 1.56 lower for blacks than for whites, p = 0.14). WOMAC pain and function scores 2 years after TKA worsen with increasing levels of community poverty, but do so to a greater extent among blacks than whites. Disparities in pain and function between blacks and whites are evident only in the poorest communities; decreasing in a linear fashion as poverty increases. In census tracts with greater than 40% poverty, blacks score 6 ± 3 points lower (worse) than whites for WOMAC pain (p = 0.03) and 7 ± 3 points lower than whites for WOMAC function (p = 0.01). Blacks and whites living in communities with little poverty have similar patient-reported TKA outcomes, whereas in communities with high levels of poverty, there are important racial disparities. Efforts to improve TKA outcomes among blacks will need to address individual- and community-level socioeconomic factors. Level III, therapeutic study.

Background: Poverty is associated with increased risk of chronic illness, but its contribution to bloodstream infections is not well-defined. Methods: We performed a multicenter observational study of 14,657 patients, aged 18 yrs or older, who received critical care and had blood cultures drawn between 1997 and 2007 in two hospitals in Boston, Massachusetts. Data sources included 1990 U.s. Census and hospital administrative data. Census tracts were used as the geographic units of analysis. The exposure of interest was neigh- borhood poverty rate categorized as 40%. Neighborhood poverty rate is the percentage of residents with income below the federal poverty line. The primary end point was bloodstream infection occurring 48 hrs before critical care initiation to 48 hrs after. Associations between neighborhood poverty rate and bloodstream infection were estimated by logistic regression models. Adjusted odds ratios were estimated by multi- variable logistic regression models. Results: Two thousand four-hundred thirty-five patients had bloodstream infections. Neighborhood poverty rate was a strong predictor of risk of bloodstream infection, with a significant risk gradient across neighborhood poverty rate quintiles. After multi- variable analysis, neighborhood poverty rate in the highest quin- tiles (20%-40% and >40%) were associated with a 26% and 49% increase in bloodstream infection risk, respectively, relative to pa- tients with neighborhood poverty rate of

There is substantial geographic variability in both incident and prevalent arteriovenous fistula (AVF) use among patients with ESRD. This study examined the degree to which these variations associate with poverty in the county of a patient's treatment center. We performed a cross-sectional study including 28,135 patients treated by 1127 hemodialysis centers in five ESRD networks (16 states) between June 1, 2005 and May 31, 2006. We used the 2000 U.S. Census to categorize county-level poverty and ascertained incident AVF use from the Medicare CMS 2728 form. We calculated the 30-month slope of change in AVF prevalence from monthly facility reports collected between 2003 and 2005. More than 33% of treatment centers were located in high-poverty counties. County poverty inversely associated with incident AVF use (P for trend = 0.001). In contrast, substantial increases in prevalent AVF rates from 30.9 to 38.6% (P < 0.001) among treatment centers did not associate with county poverty (P = 0.9519). In conclusion, the concentration of poverty in the county where a treatment is located associates with incident AVF use by patients with ESRD but not with subsequent improvement in AVF use among prevalent patients. These results suggest that the Medicare ESRD program may mitigate poverty effects on AVF use.

Study Design. Cross-sectional study of 45- to 64-year-old Australians. Objective. To assess the relationship between chronic back problems and being in income poverty among the older working-aged population. Summary of Background Data. Older workers who leave the labor force due to chronic back problems have fragile economic situations and as such are likely to have poorer living standards. Poverty is one way of comparing the living standards of different individuals within society. Methods. The 2003 Survey of Disability, Ageing and Carers data were used, along with the 50% of the median equivalized income-unit income poverty line to identify those in poverty. Logistic regression models were used to look at the relationship between chronic back problems, labor force participation, and poverty. Results. Regardless of labor force participation status (employed full-time, part-time, or not in the labor force at all), those with chronic back problems were significantly more likely to be in poverty. Those not in the labor force due to chronic back problems were significantly more likely to be in poverty than those in the labor force full-time with no chronic health condition (Odds ratio [OR]: 0.07, 95% CI: 0.07–0.07, P < 0.0001). Further, those employed part-time with no chronic health condition were 48% less likely to be in poverty (OR: 0.52, 95% CI: 0.51–0.53, P < 0.0001) than those also employed part-time but with chronic back problems. It was found that among those with back problems, those out of the labor force were significantly more likely to be in poverty than those employed part-time or full-time (OR: 0.44, 95% CI: 0.43–0.44, P < 0.0001; OR: 0.10, 95% CI: 0.10–0.10, P < 0.0001, respectively). Conclusion. This highlights the need to prevent and effectively treat chronic back problems, as these conditions are associated with reduced living standards.

Health is wealth. Economics is creation of wealth. There is a direct relationship between health and economics. Noma, associated with extreme poverty, can be used as an economic index.

To determine how patient race, ethnicity, and degree of poverty affect treatment and survival for acute myeloid leukemia (AML).A linked database of the Florida cancer registry and State inpatient and outpatient hospital data for 1998-2002 was queried. Effects of demographic and treatment characteristics on survival were explored using univariate and multivariate analyses methods.A total of 4659 patients with AML were identified. Over 50% of patients with AML were 70 years of age or older. African American (AA) patients were diagnosed at significantly younger ages than were whites (P0.001). In multivariate analysis, independent predictors of worse survival in AML were aged over 50 (hazard ratios [HRs]: 1.60, 2.15, 3.04, and 3.62 over the decade-cohorts, all P0.001), AA race (HR: 1.27, P0.001), being a former or current user of tobacco (HR: 1.13, P = 0.004 and HR: 1.28, P0.001, respectively), residing in an area with the highest poverty level (HR: 1.15, P = 0.007), and being covered only by Medicaid (HR: 1.23, P = 0.014). No differences in outcomes were observed related to gender or ethnicity. Receipt of chemotherapy was strongly associated with improved survival (HR: 0.59, P0.001). When only those patients who received and appeared to respond to treatment are included, AAs continued to demonstrate a worse outcome than Whites.AML disproportionately affects the elderly. AA patients and patients from poorer communities with AML have significantly worse survival. Interventions to provide earlier diagnosis in these patients as well as to improve overall outcomes are needed to address these disparities.

Epidemiologists cannot afford to ignore poverty. To do so would, first, wrongly obscure the devastating impact of poverty on population health, and, second, undercut our commitment to scientific rigor. At issue is doing correct science, not "politically correct" science. Blot poverty and inequity from view, and not only will we contribute to making suffering invisible but our understanding of disease etiology and distribution will be marred. To make this case, I address current debates about the causal relationships between poverty and health, and provide examples of how failing to consider the impact of socioeconomic position has biased epidemiologic knowledge and harmed the public's health. By definition, the people we study are simultaneously social beings and biologic organisms-and we cannot study the latter without taking into account the former. It is the responsibility of all epidemiologists, and not only social epidemiologists, to keep in mind the connections between poverty and health.

Monitoring social inequalities in sexual health is important to the effective allocation of resources for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention by state health departments and other outside planning groups. At the Virginia Department of Health, like most US public health agencies, there is a lack of consistent socioeconomic data, such as individual-level poverty measures, collected through routine disease surveillance.1 As a result, state epidemiologists are only able to provide a general description of poverty, such as the percentage of people living in poverty while providing HIV/STI rates for the same administrative area.2–8 This article has 2 objectives. The first is to quantify and compare HIV/STI incidence across 4 stratum of poverty at the census tract level in Virginia using methods developed by the Public Health Disparities Geocoding Project.9 Second, for each poverty strata we examine the distribution of HIV-positive and other high-risk populations, identified as priority concerns for HIV prevention planning in Virginia (“priority populations”). This research can help epidemiologists and outside planning groups, who often lack access to geocoded data guide resource allocation for HIV/STI prevention. The Public Health Disparities Geocoding Project helps facilitate routine monitoring of health inequities in the United States by providing epidemiologists with an established statistical framework for comparing disease rates at the census tract level to a census tract-based measure of poverty.9 The methodology for monitoring socioeconomic inequalities through quantifying the relationship between infection rates and area-based socioeconomic measures (ABSM) was developed and is described by the Public Health Disparities Geocoding Project. Briefly, outcomes were geocoded to the census tract level, tracts were stratified into discrete poverty levels (0%– 4.9%, 5.0%–9.9%, 10.0%–19.99%, and 20%–100% population living below poverty), age-standardized incidence rates were calculated for each stratum of poverty, and 95% confidence intervals based on the distribution were calculated.9 To calculate infection rates at the census tract level, we geocoded clinically diagnosed cases of HIV [regardless of transition to acquired immune deficiency syndrome (AIDS)], chlamydia (CT), gonorrhea (NG), and total early syphilis (TES) between 2000 and 2005 using addresses obtained from Virginia’s HIV and AIDS Reporting System (HARS) and the STD Management Information System (STDMIS). Geocoding was performed with Centrus Geostan.10 Each census tract in Virginia was stratified into 1 of 4 discrete poverty stratum, which are defined by an area-based socioeconomic measure created by the Public Health Disparities Geocoding Project from 2000 census data.11 Each stratum is an aggregation of census tracts based on the percentage of the tract’s total population living below the federal poverty line. Four hundred eighty (31%), 428 (28%), 418 (27%), and 206 (13%) census tracts were assigned to the 0% to 4.9%, 5.0% to 9.9%, 10.0% to 19.9%, and 20.0% to 100% stratum, respectively. Age-standardized incidence rates and incidence rate ratios (IRRs) for each disease were calculated for each stratum of poverty, and 95% confidence intervals based on the distribution were calculated. Gamma intervals are commonly used when the outcomes are directly standardized rates and a small number of cases and a large variability in weights exists.12 Addresses were considered geocodable to the census tract level if they geocoded to a street/house/intersection, the center of a block group/census tract or the center of a zip code, where The authors wish to thank Rene Cabral-Daniels, Jason Carr, Jeanette Gustat, Hongjie Liu and Jeff Stover, for their careful review of the manuscript. This activity was conducted, in part, through the support of the Centers for Disease Control and Prevention (CDC) Cooperative Agreement No. U62-PS000559, “Evaluating Integration of HIV/AIDS Surveillance Data with a Geographic Information System.” Additional support was provided through ongoing collaborative activities associated with the Outcomes Assessment through Systems of Integrated Surveillance (OASIS) workgroup, which was a CDC funded activity from 1998 through 2005. The Health Informatics and Integrated Surveillance Systems staff within the Virginia Department of Health-Division of Disease Prevention are grateful for the impetus OASIS had on our geographic information systems initiatives, our analytical infrastructure and our public health network of colleagues. Correspondence: Carrie Dolan, MPH, 5308 Discovery Park Building, Suite 101, Williamsburg, VA 23188. E-mail: cdolan@wchf.com. Received for publication August 30, 2007, and accepted June 7, 2008. From the Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia Sexually Transmitted Diseases, December 2008, Vol. 35, No. 12, p.981–984 DOI: 10.1097/OLQ.0b013e318182a571 Copyright © 2008, American Sexually Transmitted Diseases Association All rights reserved.

Noma (necrotizing ulcerative stomatitis, stomatitis gangrenosa, or cancrum oris) is a devastating orofacial gangrene that occurs mainly among children. The disease has a global yearly incidence of 140,000 cases and a mortality rate of approximately 90 percent. Patients who survive noma generally suffer from its sequelae, including serious facial disfigurement, trismus, oral incontinence, and speech problems. The medical history of noma indicates that the disease was already known in classical and medieval civilizations in Europe. In the sixteenth and seventeenth centuries, Dutch chirurgeons clearly described noma as a clinical entity and realized that the popular name "water canker" was not sufficient, because this quickly spreading ulceration in the faces of children was different from "cancer." In the eighteenth century, awareness that noma is related to poverty, malnutrition, and preceding diseases such as measles increased in northwestern Europe. In the first half of the nineteenth century, extensive surgical procedures were described for the treatment of the sequelae of noma. At the end of that century, noma gradually disappeared in the Western world because of economic progress, which gave the poorest in society the opportunity to feed their children sufficiently. Only in the twentieth century were effective drugs (sulfonamides and penicillin) against noma developed, as well as adequate surgical treatment for the sequelae of noma. These modes of treatment remain inaccessible for the many present-day victims of noma because of their extreme poverty. The only truly effective approach to the problem of noma throughout the world is prevention, namely, combating the extreme poverty with measures that lead to economic progress. In the meantime, medical doctors in the Western world should not forget their own history and ignore this global health problem; rather, they should face "the face of poverty" with the eyes of mercy and concern suited to their profession.

Background and Purpose— The greater mortality and residual physical impairments among black stroke patients may be attributable to differential utilization of rehabilitation services. This report examines, within an equal-access healthcare system, racial differences in time to initiation of stroke rehabilitation services and in the trajectory of physical function recovery. Methods— This study was a secondary analysis of data from an inception cohort of 1073 stroke patients hospitalized between April 1995 and March 1997 and followed up for up to 1 year. Inpatient data came from medical record reviews; follow-up data came from telephone interviews at 1, 6, and 12 months after stroke. The study included consecutive acute ischemic or intracerebral hemorrhagic stroke patients from 9 VA medical centers. The main outcome measures were time to initiation of inpatient rehabilitation services and ability to perform activities of daily living. Results— There were no racial differences in receipt of inpatient rehabilitation services (blacks, 76%; whites, 70%) or in the proportion of patients referred within 3 days of admission (blacks, 43.5%; whites, 42.0%). Among patients who experienced delay in initiation of rehabilitation, only low-income blacks experienced worse functional recovery over 12 months. Conclusions— Low-income black stroke patients who experience delay in initiation of inpatient rehabilitation have a worse trajectory of functional recovery in the first year after stroke. Poverty-associated factors in the postdischarge setting may explain this phenomenon.

Social and ecologic factors, such as residential segregation, are determinants of health in the general population, but how these factors associate with outcomes among patients with ESRD is not well understood. Here, we examined associations of income inequality and residence, as social determinants of health, with survival among black and white patients with ESRD. We merged U.S. Renal Data System data from 589,036 patients who started hemodialysis from 2000 through 2008 with race-specific median household income data from the Census Bureau. We used Gini Index coefficients to assess income distributional inequality and the Dissimilarity Index to determine residential segregation. Black patients lived in areas of lower median household income compared with white patients ($26,742 versus $41,922; P

Few people in the world today are rich; the vast majority, 86% of the global population, live in the developing world, in countries that are classified as low or middle income.1 The most recent data on extreme poverty suggest that nearly a billion people, spread over many continents, live on less than one dollar per day.2 It is in low and middle income (LAMI) countries where most cases of neurologic disease occur, including stroke, epilepsy, primary headache disorders, and Alzheimer disease,3 and in these countries neurologic disease is studied little if at all. The public health challenges for neurologic disorders in LAMI countries are multiple. Among the poor, there is special consideration of the 1) overall burden of neurologic disease, 2) lack of access to essential medications, 3) paucity of epidemiologic research available, 4) reduced ratio of practitioners in LAMI countries, 5) double burden of communicable and noncommunicable disease, and 6) stigma. At every level of society, there is a need for more education, in rich countries as well as poor ones. Health care workers, students, governments, teachers, and members of the general public all have important roles to play. Dementia and stroke are among the most common disabling diseases worldwide,4 and in some regions of the world, stroke accounts for more deaths than ischemic heart disease. Although often considered developed world diseases, 86% of all stroke mortality5 and 85% of all cases of epilepsy3 occur in the developing world. Overall, neurologic disorders now account for a greater burden of disease than HIV/AIDS.4 Studies from LAMI countries reveal poor access to underprescribed and often unaffordable medications. In one recent analysis6 of four low and six middle income …

Although the impact of poverty on the health and development of children is readily acknowledged, the extent of accompanying visual functional and perceptual-motor disorders has not received very much attention. These visual disorders are shown to be linked with poverty. In particular, research studies to support the notion that neurointegrative and concomitant visual problems can be the result of malnutrition, low birthweight, teenage pregnancy, and maternal complications of pregnancy are cited and discussed. The association between perceptuo-cognitive functioning in children and sociodemographic factors are examined and related to central nervous system maturation in a hostile environment. The role of the optometrist in diagnosing and treating children with visual and neurointegrative problems is reviewed. Special emphasis is placed on the potential for optometric intervention to improve the ability of disadvantaged children to respond more effectively to classroom learning and enable them to make fuller use of the intelligence they possess. The authors recommend that optometrists play a vital role in their communities to ensure the rendering of appropriate professional treatment for economically impoverished and socially disadvantaged children.

Imagine waking up on the dirt floor of a shack after a fitful nights sleep that was disrupted by insect bites suffocating heat and no indoor plumbing. You are hungry and uncertain when you will get something to eat and you realize that the not-so-pure water for drinking and for cooking anything you may get to eat is over a mile away on foot through terrain that holds other dangers. Every day begins and ends this way for most people living in resource-poor areas of our planet. This description does not take into account illness-related symptoms such as weakness diarrhea weight loss fevers chills exhaustion vomiting coughing and other problems caused by HIV malaria or tuberculosis. Nor does this story capture the responsibilities adults and far too many children bear as parents breadwinners crop and livestock managers caregivers for the sick protectors or all of the above. This story also fails to describe the impact on communities devastated by HIV/AIDS or on the thousands of children left orphaned living alone and needing to be taken in by already stressed older relatives or community members. (excerpt)

The aim of the United Nations Millennium Development Goals (MDGs) is to reduce by 50% the number of people throughout the world living on less than $1 a day by finding solutions to poverty hunger disease illiteracy environmental pollution and discrimination against women. All of these concerns are inextricably linked; poverty in particular compromises the health of women and children throughout the world. This is clearly stated by the United Nations International Childrens Emergency Fund (2005): "Poverty threatens every right depriving children of the capacities they require to survive develop and thrive (p. 36)." Three of the eight MDGs focus directly on health including the reduction of maternal and child mortality rates. Disease-specific issues have captured international attention and funding focuses on infections such as HIV/AIDS and other infectious diseases. Although these issues are important and merit interventions global funding should focus on preventive maternal child healthrather than disease-specific issues. For example sexually transmitted infections and HIV/AIDS constitute 5.8% of the total disease burden and receive 23.6% of development assistance whereas maternal illness represents 8.3% of the disease burden and receives only 16% of development assistance. Such "stovepipe" funding may weaken healthcare systems that focus on health promotion and disease prevention and the most vulnerable marginalized impoverished and often voiceless women and children may lack the most essential services. (excerpt)

Our prior research has demonstrated that increasing the number of trauma centers (TCs) in a state does not reliably improve state-level injury-related mortality. We hypothesized that many new TCs would serve populations already served by existing TCs, rather than in areas without ready TC access. We also hypothesized that new TCs would also be less likely to serve economically disadvantaged populations.All state-designated adult TCs registered with the American Trauma Society in 2014 and 2019 were mapped using ArcGIS Pro (ESRI Inc., Redlands, CA). Trauma centers were grouped as Level 1 or 2 (Lev12) or Level 3, 4 or 5 (Lev345). We also obtained census tract-level data (73,666 tracts), including population counts and percentage of population below the federal poverty threshold. Thirty-minute drive-time areas were created around each TC. Census tracts were considered "served" if their geographic centers were located within a 30-minute drive-time area to any TC. Data were analyzed at the census tract level.A total of 2,140 TCs were identified in 2019, with 256 new TCs and 151 TC closures. Eighty-two percent of new TCs were Levels 3 to 5. Nationwide, coverage increased from 75.3% of tracts served in 2014 to 78.1% in 2019, representing an increased coverage from 76.0% to 79.4% of the population. New TC served 17,532 tracts, of which 87.3% were already served. New Lev12 TCs served 9,100 tracts, of which 91.2% were already served; new Lev345 TCs served 15,728 tracts, of which 85.9% were already served. Of 2,204 newly served tracts, those served by Lev345 TCs had higher mean percentage poverty compared with those served by Lev12 TCs (15.7% vs. 13.2% poverty, p0.05).Overall, access to trauma care has been improving in the United States. However, the majority of new TCs opened in locations with preexisting access to trauma care. Nationwide, Levels 3, 4, and 5 TCs have been responsible for expanding access to underserved populations.Prognostic and Epidemiologic; Level IV.

BACKGROUND: Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. METHODS: We identified 1,515,986 individuals (aged 18–84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. RESULTS: County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (−4.94 per 1000 PY), lower transplant rate (−4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality. CONCLUSIONS: Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.

In 2020, obesity prevalence among US children reached 19.7%, impacting about 14.7 million children and adolescents. Food insecurity among children is also a public health concern but has largely decreased or remained stable over the past decade, reaching 6.2% of US households with children in 2021. Given food insecurity and obesity's interconnected nature and their negative consequences on children's health, it is of interest to assess the Supplemental Nutrition Assistance Program's (SNAP's) impact on childhood food security, dietary quality, disease risk, and health outcomes.Evidence suggests that SNAP participants, including children, struggle to meet key dietary guidelines and perform poorly on key health indicators when compared with income-eligible and higher income nonparticipants. Children participating in SNAP were more likely to have elevated disease risk and consume more sugar-sweetened beverages (SSBs), more high-fat dairy, and more processed meats than income-eligible nonparticipants. However, research suggests that federal food assistance programs with more stringent nutrition standards - the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the National School Lunch Program (NSLP) and School Breakfast Program (SBP) - improve dietary quality, increase birth weight and gestation periods, and reduce childhood obesity, infant mortality and healthcare costs.After reviewing the evidence on SNAP's impacts on food insecurity, dietary quality, and health as well as research on the health impacts of other more successful federal food assistance programs, we provide three policy recommendations to strengthen SNAP's effectiveness as a health intervention for children and families.

States' decisions to expand Medicaid eligibility would make most low-income uninsured people eligible for Medicaid, while also increasing the financial viability of Federally Qualified Health Centers (FQHCs) by reducing their grant to total revenue ratios. We extracted a national sample of 729 FQHCs for the period 2009 to 2018. The dependent variable was grant to revenue ratio and the independent variable was the states' Medicaid expansion status. FQHCs operating in Medicaid expansion states had lower grant ratios during the postexpansion period. As past decades' funding volatilities have shown, overreliance on one revenue source may increase financial risk. Medicaid expansion can support FQHCs by improving their long-term financial sustainability.

Background Exposure to racism and associated adversities, such as poverty, is hypothesized to contribute to racial inequities in health via stress and immune pathways. Furthermore, the effects of adversity may be more salient during sensitive developmental periods. Our study examined racial differences in stress and immune biomarkers during adolescence and the effects of exposure to economic adversity at distinct developmental time periods and cumulatively in accounting for potential racial differences. Methods Secondary analysis of the Adolescent Health and Development in Context study was conducted. Data were derived from self-administered surveys; interviews; smartphone-based, geographic-explicit ecological momentary assessment; stress biomarkers (evening salivary cortisol over six nights and hair cortisol); and immune biomarkers (salivary shedding of Epstein-Barr virus [EBV] DNA among EBV-positive adolescents). Current socioeconomic status measures included annual household income and caregiver education. Caregivers also reported experiences of bankruptcy, difficulty paying bills, receipt of food stamps/Supplemental Nutrition Assistance Program/electronic benefit transfer, and job loss when the child was of ages birth-5 years, 6-10 years, and 11 years or older. An affirmative response to any item was defined as exposure to economic adversity for that developmental time period (yes/no). A cumulative economic adversity measure was calculated as the sum of exposures across developmental periods (0 = never exposed to 3 = exposed across all time periods). Descriptive and multivariable regression analyses were conducted, accounting for covariates. Results Black/African American adolescents had higher salivary cortisol concentration, higher hair cortisol concentration, and an increased odd of salivary shedding of EBV DNA compared to White adolescents. Racial differences were not attenuated by the current socioeconomic status or economic adversity (developmental period or cumulatively). Discussion Our study provides evidence that stress and immune biomarkers differ by race as early as adolescence and may be one pathway through which racism and associated adversities contribute to racial health inequities. Further research on the contribution of multiple adversities beyond poverty to racial inequities in physiological stress and health is critical for informing effective prevention and intervention efforts.

Background Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown. Objective This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival. Design This is a retrospective database review. Settings This study was conducted by utilizing the Kentucky Cancer Registry at an academic center. Patients All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included. Main outcome measures The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival. Results Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens. Limitations This study was limited by the retrospective nature of the review and by unmeasured confounders. Conclusions Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596. Terapia neoadyuvante en el manejo del cncer de recto en estadio ii / iii un estudio retrospectivo en una poblacin dispar y el efecto en la supervivencia ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cancer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la poblacion que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atencion de alto nivel es muy bajo. El tratamiento del cancer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cancer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISENO:Revision retrospectiva de una base de datos.ESCENARIO:Este estudio se llevo a cabo utilizando el Registro de Cancer de Kentucky en un centro academico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibio terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no academicos. El analisis de la supervivencia mostro una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparacion con otros esquemas de tratamiento.LIMITACIONES:Revision retrospectiva, factores de confusion no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cancer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta poblacion, por lo tanto se deben hacer esfuerzos en las politicas de salud, asi como en educacion, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no academicos. El centralizar la atencion del cancer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales economicamente, con acceso deficiente a la posibilidad de recibir atencion de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

Residential histories linked to cancer registry data provide new opportunities to examine cancer outcomes by neighborhood socioeconomic status (SES). We examined differences in regional stage colon cancer survival estimates comparing models using a single neighborhood SES at diagnosis to models using neighborhood SES from residential histories.We linked regional stage colon cancers from the New Jersey State Cancer Registry diagnosed from 2006 to 2011 to LexisNexis administrative data to obtain residential histories. We defined neighborhood SES as census tract poverty based on location at diagnosis and across the follow-up period through 31 December 2016 based on residential histories (average, time-weighted average, time-varying). Using Cox proportional hazards regression, we estimated associations between colon cancer and census tract poverty measurements (continuous and categorical), adjusted for age, sex, race/ethnicity, regional substage, and mover status.Sixty-five percent of the sample was nonmovers (one census tract); 35% (movers) changed tract at least once. Cases from tracts with20% poverty changed residential tracts more often (42%) than cases from tracts with5% poverty (32%). Hazard ratios (HRs) were generally similar in strength and direction across census tract poverty measurements. In time-varying models, cases in the highest poverty category (20%) had a 30% higher risk of regional stage colon cancer death than cases in the lowest category (5%) (95% confidence interval [CI] = 1.04, 1.63).Residential changes after regional stage colon cancer diagnosis may be associated with a higher risk of colon cancer death among cases in high-poverty areas. This has important implications for postdiagnostic access to care for treatment and follow-up surveillance. See video abstract: http://links.lww.com/EDE/B705.

Context Nearly 1.2 million children with disabilities received federally administered Supplemental Security Income (SSI) payments in 2017. Based on a robust review of research and evaluation evidence and microsimulations, The National Academies of Sciences, Engineering, and Medicine committee identified modifications to SSI (ie, increasing the federal SSI benefit maximum by one-third or two-thirds) as 1 of 10 strategies that could reduce the US child poverty rate, improving child health and well-being on a population level. Objective Describing the availability and amount of SSI and State Supplementary Payment (SSP) program benefits to support families of children with disabilities may be a first step toward evaluating The National Academies of Sciences, Engineering, and Medicine-proposed modification to SSI as a potential poverty alleviation and health improvement tool for children with disabilities and their families. Design We used public health law research methods to characterize the laws (statutes and state agency regulations) governing the federal SSI program and SSP programs in the 50 states and District of Columbia from January 1, 1996, through November 1, 2018. Results The number of jurisdictions offering supplementary payments (SSP) was relatively stable between 1996 and 2018. In 2018, 23 US jurisdictions legally mandated that SSP programs were available for children. Among the states with SSP payment amounts in their codified laws, SSP monthly benefit amounts ranged from $8 to $64.35 in 1996 and $3.13 to $60.43 in 2018. Conclusion Our initial exploration of SSI-related policies as a tool for improving the economic stability of children with disabilities and their families suggests that current SSPs, in combination with SSI, would not rise to the level of SSI increases proposed by The National Academies of Sciences, Engineering, and Medicine. Understanding more about how SSI and SSP reach children and work in combination with other federal and state income security programs may help identify policies and strategies that better support children with disabilities in low-income households.

To summarize the impact of the COVID-19 pandemic on food insecurity during early childhood, with a focus on challenges and strategies to improve access to and consumption of nutritious food in early childcare and education settings.The COVID-19 pandemic exacerbated existing gaps and inequities in the early childcare and education system, resulting in closures and decreased access to healthy foods that disproportionately impacted black, indigenous, and people of color, as well as rural and low-income communities.Closures and changes in operational capacity not only stressed the early childcare and education system and its workforce but also contributed to financial strain and food insecurity among families with young children. Increased public investment and cross-sector partnerships can support and strengthen both early childcare and education and food systems, increasing equitable access to quality care and reducing food insecurity in early childhood.

To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States.Retrospective, cross-sectional study.Contiguous United States.Children less than 18 years as represented in the 2016 American Community Survey.None.Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas.In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.

BACKGROUND HIV-related discrimination in health care settings is associated with negative health outcomes among persons with HIV (PWH). This article describes and compares differences in the prevalence of self-reported experiences with discrimination in health care settings by sociodemographic and clinical care factors among persons with diagnosed HIV in the United States. METHODS We analyzed interview and medical record data collected during June 2018-May 2019 from 3850 PWH who had received HIV care in the past 12 months. We calculated weighted percentages and associated 95% confidence intervals and assessed the association between any experience of discrimination and selected sociodemographic and clinical characteristics using prevalence ratios with predicted marginal means. RESULTS Approximately 25% of PWH who had an HIV care visit in the past 12 months reported experiencing any discrimination. Experiences with discrimination were significantly more prevalent among persons aged 18-29 years (34%); transgender persons (41%); persons of gay (25%), bisexual (31%), or other (40%) sexual orientations; and persons who did not have a regular provider (39%), lived at/below poverty level (28%), were homeless (39%) or incarcerated (37%) in the past 12 months. PWH who experienced discrimination were more likely to have missed at least one HIV care visit, not be taking antiretroviral therapy, and have missed antiretroviral therapy doses. Recent and sustained viral suppression were not significantly associated with experiencing any discrimination. CONCLUSIONS Interventions that address the sociocultural and structural factors associated with discrimination in all health care settings are needed to improve health outcomes among PWH and end the HIV epidemic in the United States.

PURPOSE OF REVIEW Climate change remains a major threat to the health and well-being of children globally. This article reviews the myriad health effects of climate change on children throughout their lives and discusses ways in which the general pediatrician can be an advocate for climate solutions. RECENT FINDINGS Rising atmospheric temperatures, increased air pollution, and destabilized weather patterns all lead to adverse health outcomes for children and adverse obstetric outcomes. However, the impact of climate change is not evenly distributed. Children living in poverty are more likely to be adversely impacted by the changing climate. SUMMARY Ongoing and emerging research suggests that children are particularly vulnerable to the effects of climate change. The primary care pediatrician is encouraged to see this irrefutable evidence as a call to action for advocacy on behalf of our patients and the planet.

Objectives Factors common to socioeconomically disadvantaged neighborhoods, such as low availability of transportation, may limit access to restorative care services for critical illness survivors. Our primary objective was to evaluate whether neighborhood socioeconomic disadvantage was associated with an increased disability burden after critical illness. Our secondary objective was to determine if the effect differed for those discharged to the community compared with those discharged to a facility. Design Longitudinal cohort study with linked Medicare claims data. Setting United States. Patients One hundred ninety-nine older adults, contributing to 239 ICU admissions, who underwent monthly assessments of disability for 12 months following hospital discharge in 13 different functional tasks from 1998 to 2017. Measurements and main results Neighborhood disadvantage was assessed using the area deprivation index, a 1-100 ranking evaluating poverty, housing, and employment metrics. Those living in disadvantaged neighborhoods (top quartile of scores) were less likely to self-identify as non-Hispanic White compared with those in more advantaged neighborhoods. In adjusted models, older adults living in disadvantaged neighborhoods had a 9% higher disability burden over the 12 months following ICU discharge compared with those in more advantaged areas (rate ratio, 1.09; 95% Bayesian credible interval, 1.02-1.16). In the secondary analysis adjusting for discharge destination, neighborhood disadvantage was associated with a 14% increase in disability burden over 12 months of follow-up (rate ratio, 1.14; 95% credible interval, 1.07-1.21). Disability burden was 10% higher for those living in disadvantaged neighborhoods and discharged home as compared with those discharged to a facility, but this difference was not statistically significant (interaction rate ratio, 1.10; 95% credible interval, 0.98-1.25). Conclusions Neighborhood socioeconomic disadvantage is associated with a higher disability burden in the 12 months after a critical illness. Future studies should evaluate barriers to functional recovery for ICU survivors living in disadvantaged neighborhoods.