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Importance: Prior studies on the association between fine particulate matter with diameters 2.5 μm or smaller (PM2.5) and probability of death have not applied multilevel analysis disaggregating data for US census tract, states, and counties, nor tested its interaction by socioeconomic status (SES). Such an approach could provide a more refined identification and targeting of populations exposed to increased risk from PM2.5., Objective: To assess the association between PM2.5 and age-specific mortality risk (ASMR) using disaggregated data at the census tract level and evaluate such association according to census tract SES., Design, Setting, and Participants: This nationwide cross-sectional study used a linkage of 3 different data sets. ASMR for the period of 2010 to 2015 was obtained from the National Center for Health Statistic, SES data covering a period from 2006 to 2016 came from the American Community Survey, and mean PM2.5 exposure levels from 2010 to 2015 were derived from well-validated atmospheric chemistry and machine learning models. Data were analyzed in April 2021., Exposures: The main exploratory variable was mean census tract-level long-term exposure to PM2.5 from 2010 to 2015., Main Outcomes and Measures: The primary outcome was census tract-level ASMR. Multilevel models were used to quantify the geographic variation in ASMR at levels of census tract, county, and state. Additional analysis explored the interaction of SES in the association of ASMR with PM2.5 exposure., Results: Data from 67 148 census tracts nested in 3087 counties and 50 states were analyzed. The association between exposure to PM2.5 and ASMR varied substantially across census tracts. The magnitude of such association also varied across age groups, being higher among adults and older adults. Census tracts accounted for most of the total geographic variation in mortality risk (range, 77.0%-94.2%). ASMR was higher in deciles with greater PM2.5 concentration. For example, ASMR for age 75 to 84 years was 54.6 per 1000 population higher in the decile with the second-highest PM2.5 concentration than in the decile with the lowest PM2.5 concentration. The ASMR, PM2.5 concentrations, and magnitude of the association between both were higher in the census tracts with the lowest SES., Conclusions and Relevance: This cross-sectional study found that census tracts with lower SES presented higher PM2.5 concentrations. ASMR and air pollution varied substantially across census tracts. There was an association between air pollution and ASMR across all age groups in the United States. These findings suggest that equitable public policies aimed at improving air quality are needed and important to increase life expectancy.

Studies on geographic inequalities in life expectancy in the United States have exclusively focused on single-level analyses of aggregated data at state or county level. This study develops a multilevel perspective to understanding variation in life expectancy by simultaneously modeling the geographic variation at the levels of census tracts (CTs), counties, and states. We analyzed data from 65,662 CTs, nested within 3,020 counties and 48 states (plus District of Columbia). The dependent variable was age-specific life expectancy observed in each of the CTs. We also considered the following CT-level socioeconomic and demographic characteristics as independent variables: population density; proportions of population who are black, who are single parents, who are below the federal poverty line, and who are aged 25 or older who have a bachelor's degree or higher; and median household income. Of the total geographic variation in life expectancy at birth, 70.4% of the variation was attributed to CTs, followed by 19.0% for states and 10.7% for counties. The relative importance of CTs was greater for life expectancy at older ages (70.4 to 96.8%). The CT-level independent variables explained 5 to 76.6% of between-state variation, 11.1 to 58.6% of between-county variation, and 0.7 to 44.9% of between-CT variation in life expectancy across different age groups. Our findings indicate that population inequalities in longevity in the United States are primarily a local phenomenon. There is a need for greater precision and targeting of local geographies in public policy discourse aimed at reducing health inequalities in the United States., Competing Interests: The authors declare no competing interest.

Introduction: Health-risk behaviours tend to co-occur among the same sectors of the population. The aim of this study is to examine the association between an aggregate of multiple health-risk behaviours and tooth loss among American Adults., Methods: We used data from the Behavioural Risk Factor Surveillance System (BRFSS) 2022, a nationally representative survey of non-institutionalized American. We included participants aged 18 years and older. An aggregate variable of health-risk behaviours which included smoking, heavy alcohol consumption, lack of physical activities, overweight/obesity, infrequent dental visits and infrequent medical check-up was created. Tooth loss was indicated by losing one tooth or more. Logistic Regression analysis was conducted to test the association between the aggregate of behaviours and tooth loss adjusting for income, education, ethnicity and health insurance., Results: The analysis included 326,561 participants. The mean number of health-risk behaviours was 2.13 and 1.72 among participants with tooth loss and without tooth loss, respectively. The aggregate of health-risk behaviours was significantly associated with tooth loss with odds ratios 1.23 (95% CI, 1.21, 1.26) in a model adjusting for age, gender, education, income ethnicity and health insurance., Conclusion: This study demonstrated that an aggregate of health-risk behaviours, with some not directly linked to oral health, is associated with tooth loss among American adults. The study highlights the importance of considering different risk factors when planning health promotion policies to tackle oral health., (© 2024 The Authors. International Journal of Dental Hygiene published by John Wiley & Sons Ltd.)

Objectives: While physical health status is known to impact social functioning, a growing literature suggests that social well-being may affect oral health. This investigation evaluated whether self-perceived quality of social roles, activities and relationships (social well-being) influences gingival inflammation., Methods: Data were from the Population Assessment of Tobacco and Health Study, a nationally representative cohort of US adults, biennial waves 4 (2017) to 6 (2021). Social well-being was derived from the validated PROMIS Global-10 survey instrument, categorized for this longitudinal analysis as high, moderate or low. The main outcome was incident self-reported gum bleeding (dichotomous, proxy for gingivitis). Survey-weighted logistic regression modelling adjusted for overall health status, sociodemographic (e.g. age, sex, race/ethnicity), socioeconomic (e.g. income, education) and behavioural (e.g. tobacco, alcohol) confounders and was used to predict marginal mean gum bleeding incidence., Results: Cross-sectionally at wave 4 (N = 23 679), gum bleeding prevalence was higher along a stepwise gradient of decreasing satisfaction with social activities and relationships (extremely satisfied: 20.4%; not at all: 40.1%). Longitudinally, among participants who had never reported gum bleeding through wave 4 (N = 9695), marginal predicted new gum bleeding at wave 6 was greater with each category of lower wave 4-5 social well-being (high: 7.6%; moderate: 8.6%; low: 12.4%). Findings were robust to alternative model specifications. Results should be interpreted considering study limitations (e.g. potential unmeasured confounding; outcome by self-report)., Conclusions: Social functioning may affect physical health. Specifically, social roles, activities and relationships may influence inflammatory oral conditions, like gingivitis. Confirmatory research is warranted, along with policies and interventions that promote social well-being., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Policy PointsPolicymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures.Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities.Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long‐term policy solutions including reparations are needed to address these underlying processes. Context: The growing rate of rural hospital closures elicits concerns about declining access to hospital‐based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure—Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. Methods: To calculate spatial access, we estimated the network travel distance and time between the census tract–level population‐weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital‐based care in 2018, we estimated three‐level (tract, county, state‐level) generalized linear models. Findings: We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. Conclusions: Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Single‐item self‐reported oral health (SROH) is a convenient and reliable measure for the assessment of population‐based oral health. However, little is known about trends and its associations among US adults. This study investigated trends in SROH (aged 20+ years) and the associated factors among adults living in the United States. Methods: Self‐reported oral health data for 41 621 adults aged 20+ years from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2014 were analysed. Survey‐weighted descriptive statistics were computed to provide nationally representative estimates. Multivariable logistic regression was performed separately for each survey period with SROH as the primary outcome. Independent variables included were age, gender, race/ethnicity, education level and family poverty income ratio or PIR. Pooled survey‐weighted multivariable logistic regression was also performed to consider possible time‐changing effects. Results: The survey‐weighted proportions of “excellent or very good” in SROH increased from 27% in 1999‐2000 (n = 4873) to 38% in 2013‐2014 (n = 5765). Separate multivariable logistic analyses for each survey period suggested that females, Whites (vs Mexican and Black Americans) as well as respondents from high family PIR had higher odds of reporting their oral health as “excellent or very good” (P < .05). The pooled multivariable logistic model confirmed results in the separate logistic regression, and respondents in the more recent survey periods had higher probabilities of reporting “excellent or very good” oral health. Respondents aged 50‐59 years were found to have relatively lower probabilities of reporting “excellent or very good” oral health, while people aged 20‐29 years had higher probabilities than those aged 30‐39 years. Compared to respondents with lower education, those with higher education were more likely to report their oral health as excellent or very good. Conclusions: Self‐reported oral health improved from 1999 to 2014. In general, respondents who were young, female, White, had higher education or higher income or were surveyed in more recent years reported excellent or very good oral health. [ABSTRACT FROM AUTHOR]

Objectives. We explored the interrelationships among diabetes, hypertension, and missing teeth among underserved racial/ethnic minority elders. Methods. Self-reported sociodemographic characteristics and information about health and health care were provided by community-dwelling ElderSmile participants, aged 50 years and older, who took part in community-based oral health education and completed a screening questionnaire at senior centers in Manhattan, New York, from 2010 to 2012. Results. Multivariable models (both binary and ordinal logistic regression) were consistent, in that both older age and Medicaid coverage were important covariates when self-reported diabetes and self-reported hypertension were included, along with an interaction term between self-reported diabetes and self-reported hypertension. Conclusions. An oral public health approach conceptualized as the intersection of 3 domains--dentistry, medicine, and public health--might prove useful in place-based assessment and delivery of services to underserved older adults. Further, an ordinal logit model that considers levels of missing teeth might allow for more informative and interpretable results than a binary logit model. [ABSTRACT FROM AUTHOR]

Objective To assess changes over time of the absolute and relative household income-related inequalities in inadequate dentition (ID) among Australians, Brazilians and USA adults. Methods This study used nationwide oral health survey data from Australia ( n = 1200 in 1999; n = 2729 in 2005), Brazil ( n = 13 431 in 2003; n = 9779 in 2010) and USA ( n = 2542 in 1999; n = 1596 in 2005). Absolute income inequalities were calculated using Absolute Concentration Index (ACI) and Slope Index of Inequality (SII), while relative inequalities were calculated using Relative Concentration Index (RCI) and Relative Index of Inequality (RII). Results Prevalence of ID in the studied period dropped from 8.7% to 3.1% in Australia; from 42.1% to 22.4% in Brazil; and remained stable in USA, nearly 8.0%. Absolute income inequalities were highest in Brazil, followed by the USA and Australia; relative inequalities were lower in Brazil than in Australia and the USA. ID was higher among Brazilian females (2010) and for the poorest group in all countries and periods. A remarkable reduction in absolute inequalities were found in Australia [Slope Index of Inequality (SII) and AIC 60%] and in Brazil (SII 25%; ACI 33%) while relative inequalities increased both in Australia (RCI and RII 40%) and in Brazil (RCI 24%; RII 38%). No changes in absolute and relative income inequalities were found in the USA. Conclusion There were still persistent absolute and relative income inequalities in ID in all examined countries. There has been a reduction in absolute income inequalities in ID but an increase in relative income inequalities. [ABSTRACT FROM AUTHOR]

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women. Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health. Results. In the non-gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76). Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults' oral health should account for gender-based heterogeneity in financial hardship experiences. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic inequalities are associated with oral health status, either subjectively (self-rated oral health) or objectively (clinically-diagnosed dental diseases). The aim of this study is to compare the magnitude of socioeconomic inequality in oral health and dental disease among adults in Australia, Canada, New Zealand and the United States (US). Methods: Nationally-representative survey examination data were used to calculate adjusted absolute differences (AD) in prevalence of untreated decay and fair/poor self-rated oral health (SROH) in income and education. We pooled age- and gender-adjusted inequality estimates using random effects meta-analysis. Results: New Zealand demonstrated the highest adjusted estimate for untreated decay; the US showed the highest adjusted prevalence of fair/poor SROH. The meta-analysis showed little heterogeneity across countries for the prevalence of decayed teeth; the pooled ADs were 19.7 (95% CI = 16.7–22.7) and 12.0 (95% CI = 8.4–15.7) between highest and lowest education and income groups, respectively. There was heterogeneity in the mean number of decayed teeth and in fair/poor SROH. New Zealand had the widest inequality in decay (education AD = 0.8; 95% CI = 0.4–1.2; income AD = 1.0; 95% CI = 0.5–1.5) and the US the widest inequality in fair/poor SROH (education AD = 40.4; 95% CI = 35.2–45.5; income AD = 20.5; 95% CI = 13.0–27.9). Conclusions: The differences in estimates, and variation in the magnitude of inequality, suggest the need for further examining socio-cultural and contextual determinants of oral health and dental disease in both the included and other countries. [ABSTRACT FROM AUTHOR]