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Precision prevention embraces personalized prevention but includes broader factors such as social determinants of health to improve cardiovascular health. The quality, quantity, precision, and diversity of data relatable to individuals and communities continue to expand. New analytical methods can be applied to these data to create tools to attribute risk, which may allow a better understanding of cardiovascular health disparities. Interventions using these analytic tools should be evaluated to establish feasibility and efficacy for addressing cardiovascular disease disparities in diverse individuals and communities. Training in these approaches is important to create the next generation of scientists and practitioners in precision prevention. This state-of-the-art review is based on a workshop convened to identify current gaps in knowledge and methods used in precision prevention intervention research, discuss opportunities to expand trials of implementation science to close the health equity gaps, and expand the education and training of a diverse precision prevention workforce.

The neighborhoods where individuals reside shape environmental exposures, access to resources, and opportunities. The inequitable distribution of resources and opportunities across neighborhoods perpetuates and exacerbates cardiovascular health inequities. Thus, interventions that address the neighborhood environment could reduce the inequitable burden of cardiovascular disease in disenfranchised populations. The objective of this scientific statement is to provide a roadmap illustrating how current knowledge regarding the effects of neighborhoods on cardiovascular disease can be used to develop and implement effective interventions to improve cardiovascular health at the population, health system, community, and individual levels. PubMed/Medline, CINAHL, Cochrane Library reviews, and ClinicalTrials.gov were used to identify observational studies and interventions examining or targeting neighborhood conditions in relation to cardiovascular health. The scientific statement summarizes how neighborhoods have been incorporated into the actions of health care systems, interventions in community settings, and policies and interventions that involve modifying the neighborhood environment. This scientific statement presents promising findings that can be expanded and implemented more broadly and identifies methodological challenges in designing studies to evaluate important neighborhood-related policies and interventions. Last, this scientific statement offers recommendations for areas that merit further research to promote a deeper understanding of the contributions of neighborhoods to cardiovascular health and health inequities and to stimulate the development of more effective interventions.

Importance: DNA methylation (DNAm) provides a plausible mechanism by which adverse exposures become embodied and contribute to health inequities, due to its role in genome regulation and responsiveness to social and biophysical exposures tied to societal context. However, scant epigenome-wide association studies (EWAS) have included structural and lifecourse measures of exposure, especially in relation to structural discrimination., Objective: Our study tests the hypothesis that DNAm is a mechanism by which racial discrimination, economic adversity, and air pollution become biologically embodied., Design: A series of cross-sectional EWAS, conducted in My Body My Story (MBMS, biological specimens collected 2008-2010, DNAm assayed in 2021); and the Multi Ethnic Study of Atherosclerosis (MESA; biological specimens collected 2010-2012, DNAm assayed in 2012-2013); using new georeferenced social exposure data for both studies (generated in 2022)., Setting: MBMS was recruited from four community health centers in Boston; MESA was recruited from four field sites in: Baltimore, MD; Forsyth County, NC; New York City, NY; and St. Paul, MN., Participants: Two population-based samples of US-born Black non-Hispanic (Black NH), white non-Hispanic (white NH), and Hispanic individuals (MBMS; n=224 Black NH and 69 white NH) and (MESA; n=229 Black NH, n=555 white NH and n=191 Hispanic)., Exposures: Eight social exposures encompassing racial discrimination, economic adversity, and air pollution., Main Outcome: Genome-wide changes in DNAm, as measured using the Illumina EPIC BeadChip (MBMS; using frozen blood spots) and Illumina 450k BeadChip (MESA; using purified monocytes). Our hypothesis was formulated after data collection., Results: We observed the strongest associations with traffic-related air pollution (measured via black carbon and nitrogen oxides exposure), with evidence from both studies suggesting that air pollution exposure may induce epigenetic changes related to inflammatory processes. We also found suggestive associations of DNAm variation with measures of structural racial discrimination (e.g., for Black NH participants, born in a Jim Crow state; adult exposure to racialized economic residential segregation) situated in genes with plausible links to effects on health., Conclusions and Relevance: Overall, this work suggests that DNAm is a biological mechanism through which structural racism and air pollution become embodied and may lead to health inequities., Competing Interests: Conflict of interest The authors declare no conflict of interest.

Background: Health research on ambient nitrogen dioxide (NO 2 ) is sparse in Latin America, despite the high prevalence of NO 2 -associated respiratory diseases in the region. This study describes within-city distributions of ambient NO 2 concentrations at high spatial resolution and urban characteristics associated with neighbourhood ambient NO 2 in 326 Latin American cities., Methods: We aggregated estimates of annual surface NO 2 at 1 km 2 spatial resolution for 2019, population counts, and urban characteristics compiled by the SALURBAL project to the neighbourhood level (ie, census tracts). We described the percentage of the urban population living with ambient NO 2 concentrations exceeding WHO air quality guidelines. We used multilevel models to describe associations of neighbourhood ambient NO 2 concentrations with population and urban characteristics at the neighbourhood and city levels., Findings: We examined 47 187 neighbourhoods in 326 cities from eight Latin American countries. Of the roughly 236 million urban residents observed, 85% lived in neighbourhoods with ambient annual NO 2 above WHO guidelines. In adjusted models, higher neighbourhood-level educational attainment, closer proximity to the city centre, and lower neighbourhood-level greenness were associated with higher ambient NO 2 . At the city level, higher vehicle congestion, population size, and population density were associated with higher ambient NO 2 ., Interpretation: Almost nine out of every ten residents of Latin American cities live with ambient NO 2 concentrations above WHO guidelines. Increasing neighbourhood greenness and reducing reliance on fossil fuel-powered vehicles warrant further attention as potential actionable urban environmental interventions to reduce population exposure to ambient NO 2 ., Funding: Wellcome Trust, National Institutes of Health, Cotswold Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Green vegetation may protect against heat-related death by improving thermal comfort. Few studies have investigated associations of green vegetation with heat-related mortality in Latin America or whether associations are modified by the spatial configuration of green vegetation. We used data from 323 Latin American cities and meta-regression models to estimate associations between city-level greenness, quantified using population-weighted normalized difference vegetation index values and modeled as three-level categorical terms, and excess deaths from heat (heat excess death fractions [heat EDFs]). Models were adjusted for city-level fine particulate matter concentration (PM 2.5 ), social environment, and country group. In addition to estimating overall associations, we derived estimates of association stratified by green space clustering by including an interaction term between a green space clustering measure (dichotomized at the median of the distribution) and the three-level greenness variable. We stratified analyses by climate zone (arid vs. temperate and tropical combined). Among the 79 arid climate zone cities, those with moderate and high greenness levels had modestly lower heat EDFs compared to cities with the lowest greenness, although protective associations were more substantial in cities with moderate versus high greenness levels and confidence intervals (CI) crossed the null (Beta: -0.41, 95% CI: -1.06, 0.25; Beta -0.23, 95% CI: -0.95, 0.49, respectively). In 244 non-arid climate zone cities, associations were approximately null. We did not observe evidence of effect modification by green space clustering. Our results suggest that greenness may offer modest protection against heat-related mortality in arid climate zone Latin American cities., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background: The COVID-19 pandemic has shown how intraurban inequalities are likely to reinforce health and social inequalities. Studies at small area level help to visualize social inequialities hidden in large areas as cities or regions., Aim: To describe the spatial patterning of COVID-19 death rates in neighborhoods of the medium-sized city of Bariloche, Argentina, and to explore its relationship with the socioeconomic characteristics of neighborhoods., Methods: We conducted an ecological study in Bariloche, Argentina. The outcome was counts of COVID-19 deaths between June 2020 and May 2022 obtained from the surveillance system and georeferenced to neighborhoods. We estimated crude- and age-adjusted death rates by neighborhood using a Bayesian approach through a Poisson regression that accounts for spatial-autocorrelation via Conditional Autoregressive (CAR) structure. We also analyzed associations of age-adjusted death rates with area-level socioeconomic indicators., Results: Median COVID-19 death rate across neighborhoods was 17.9 (10th/90th percentile of 6.3/35.2) per 10,000 inhabitants. We found lower age-adjusted rates in the city core and western part of the city. The age-adjusted death rate in the most deprived areas was almost double than in the least deprived areas, with an education-related relative index of inequality (RII) of 2.14 (95% CI 1.55 to 2.96)., Conclusion: We found spatial heterogeneity and intraurban variability in age-adjusted COVID-19 death rates, with a clear social gradient, and a higher burden in already deprived areas. This highlights the importance of studying inequalities in health outcomes across small areas to inform placed-based interventions., (© 2023. The Author(s).)

We investigated the associations of social and built environment and demographic features of urban areas with self-rated health among adults living in four Latin American countries. We estimated multilevel models with harmonized data from 69,840 adults, nested in 262 sub-cities and 112 cities, obtained from the Salud Urbana en América Latina project. Poor self-rated health was inversely associated with services provision score at the sub-city-level and with social environment index at the city-level. We did not identify associations of built environment and demographic features with self-rated health. Approaches and policies to improve health in Latin American should be urban context-sensitive., Competing Interests: Declaration of competing interest We declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite global interest in gender disparities and social determinants of hypertension, research in urban areas and regions with a high prevalence of hypertension, such as Latin America, is very limited. The objective of this study was to examine associations of individual- and area-level socioeconomic status with hypertension in adults living in 230 cities in eight Latin America countries., Methods: In this cross-sectional study, we used harmonized data from 109,184 adults (aged 18-97 years) from the SALURBAL (Salud Urbana en America Latina/Urban Health in Latin America) project. Hypertension was assessed by self-report. Individual-, sub-city- and city-level education were used as proxies of socioeconomic status. All models were stratified by gender., Results: Higher individual-level education was associated with lower odds of hypertension among women (university education or higher versus lower than primary: odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.61-0.74) but higher odds among men (OR = 1.65; 95%CI 1.47-1.86), although in men an inverse association emerged when measured blood pressure was used (OR = 0.86; 95%CI 0.76-0.97). For both genders, living in sub-city areas with higher educational achievement was associated with higher odds of hypertension (OR per standard deviation [SD] = 1.07, 95%CI = 1.02-1.12; OR = 1.11 per SD, 95%CI = 1.05-1.18, for women and men, respectively). The association of city-level education with hypertension varied across countries. In Peru, there was an inverse association (higher city level education was associated with lower odds of hypertension) in women and men, but in other countries no association was observed. In addition, the inverse association of individual-level education with hypertension became stronger (in women) or emerged (in men) as city or sub-city education increased., Conclusion: The social patterning of hypertension differs by gender and by the level of analysis highlighting the importance of context- and gender-sensitive approaches and policies to reduce the prevalence of hypertension in Latin America., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Cable cars are part of the transport system in several cities in Latin America, but no evaluations of their effects on physical activity are available. TransMiCable is the first cable car in Bogotá, Colombia, and the wider intervention includes renovated parks and playgrounds. We assessed the effects of TransMiCable and the wider intervention on physical activity., Methods: The Urban Transformations and Health natural experiment was a prospective quasi-experimental study conducted from Feb 1, 2018, to Dec 18, 2018 (baseline, pre-intervention) and from July 2, 2019, to March 15, 2020 (post-intervention follow-up) in the TransMiCable intervention area (Ciudad Bolívar settlement) and a control area without TransMiCable (San Cristóbal settlement). A multistage strategy was used to sample households in each area, with one adult (aged ≥18 years) per household invited to participate. Eligible participants had lived in the intervention or control areas for at least 2 years and were not planning to move within the next 2 years. Physical activity was assessed among participants in the intervention and control areas before and after the inauguration of TransMiCable in Ciudad Bolívar with the International Physical Activity Questionnaire (long form) and with wearable accelerometers. Complete cases (those with baseline and follow-up data) were included in analyses. Respondents were classed as being physically active if they met 2020 WHO guidelines (≥150 min per week of moderate activity, ≥75 min per week of vigorous activity, or equivalent combinations); and accelerometery data were classified with the Freedson cut-points for adults. Data were also gathered in zonal parks (area ≥10 000 m 2 ) and neighbourhood parks (area <10 000 m 2 ) in the intervention and control areas by direct observation with the System for Observing Play and Recreation in Communities, to assess levels of physical activity before and after the TransMiCable intervention. Multilevel regression models were used to assess changes in physical activity associated with the TransMiCable intervention., Findings: Physical activity questionnaires were completed by 2052 adult participants (1289 [62·8%] women and 763 [37·2%] men; mean age 43·5 years [SD 17·7]) before the inauguration of TransMiCable. After the inauguration, the follow-up (final) questionnaire sample comprised 825 adults in the intervention group and 854 in the control group, including 357 adults in the intervention group and 334 in the control group with valid accelerometery data. 334 (40·5%) of 825 participants in the intervention group reported levels of physical activity that met the 2020 WHO guidelines during walking for transport before the intervention, and 426 (51·6%) afterwards (change 11·1 percentage points [95% CI 6·4 to 15·9]). A similar change was observed in the control group (change 8·0 percentage points [3·4 to 12·5]; adjusted odds ratio [OR] for the time-by-group interaction, intervention vs control group: 1·1 [95% CI 0·8 to 1·5], p=0·38). Time spent doing moderate-to-vigorous physical activity, measured with accelerometers, did not change in the intervention group after the inauguration of TransMiCable (change -0·8 min per day [-4·6 to 3·0]) and did not change compared with the control group (adjusted β for the time-by-group interaction: 1·4 min per day [95% CI -2·0 to 4·9], p=0·41). Moderate-to-vigorous physical activity was 52·1 min per day (SD 24·7) before and 59·4 min per day (35·2) after the inauguration of TransMiCable in new regular users who reported using TransMiCable during mandatory trips for work or education (n=32; change 7·3 min per day [-22·5 to 7·9]). After the intervention, an increase in the proportion of male individuals engaging in moderate or vigorous physical activity was observed in a renovated zonal park (adjusted OR for the time-by-group interaction, intervention vs control park: 2·7 [1·1 to 6·8], p=0·033). Female users of a renovated neighbourhood park were less likely to become engaged in moderate or vigorous physical activity than female users of the control area neighbourhood park (adjusted OR for the time-by-group interaction: 0·4 [0·1 to 0·6], p=0·019)., Interpretation: It is encouraging that walking for transport remained high in the TransMiCable intervention area when the use of private motorised transport had increased elsewhere in Bogotá. In low-income urban areas, where transport-related walking is a necessity, transport interventions should be focused on efforts to maintain participation in active travel while improving conditions under which it occurs., Funding: Wellcome Trust (as part of the Urban Health in Latin America project); Bogotá Urban Planning Department; Ministry of Science, Technology, and Innovation of Colombia; Universidad de Los Andes; Fundación Santa Fe de Bogotá; and Universidad del Norte., Translation: For the Spanish translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Epigenetic clocks are increasingly being used as a tool to assess the impact of a wide variety of phenotypes and exposures on healthy ageing, with a recent focus on social determinants of health. However, little attention has been paid to the sociodemographic characteristics of participants on whom these clocks have been based. Participant characteristics are important because sociodemographic and socioeconomic factors are known to be associated with both DNA methylation variation and healthy ageing. It is also well known that machine learning algorithms have the potential to exacerbate health inequities through the use of unrepresentative samples - prediction models may underperform in social groups that were poorly represented in the training data used to construct the model. To address this gap in the literature, we conducted a review of the sociodemographic characteristics of the participants whose data were used to construct 13 commonly used epigenetic clocks. We found that although some of the epigenetic clocks were created utilizing data provided by individuals from different ages, sexes/genders, and racialized groups, sociodemographic characteristics are generally poorly reported. Reported information is limited by inadequate conceptualization of the social dimensions and exposure implications of gender and racialized inequality, and socioeconomic data are infrequently reported. It is important for future work to ensure clear reporting of tangible data on the sociodemographic and socioeconomic characteristics of all the participants in the study to ensure that other researchers can make informed judgements about the appropriateness of the model for their study population., Competing Interests: The authors declare no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press.)

Background: The association of the built environment and the structural availability of services/amenities with adolescent birth rates (ABR) has been overlooked in Latin America. We investigated the association of the availability, and changes in the availability, of services/amenities with ABR in 92 Mexican cities., Methods: We estimated ABR using data on live birth registration linked to municipality of residence at the time of birth from 2008-2017. The number of services/amenities were obtained from the National Statistical Directory of Economic Units in 2010, 2015, and 2020 and grouped as follows: education, health care, pharmacies, recreation, and on- and off-premises alcohol outlets. Data were linearly interpolated to obtain yearly estimates. We estimated densities per square km by municipality. We fitted negative binomial hybrid models, including a random intercept for municipality and city, and adjusted for other social environment variables., Results: After adjustment a 1-unit increase in the density of recreation facilities, pharmacies, and off-premises alcohol outlets within municipalities was associated with a 5%, 4% and 12% decrease in ABR, respectively. Municipalities with higher density of education, recreational and health care facilities had a lower ABR; in contrast, municipalities with a higher density of on-premises alcohol experienced a higher ABR., Conclusion: Our findings highlight the importance of economic drivers and the need to invest in infrastructure, such as pharmacies, medical facilities, schools, and recreation areas and limit the availability of alcohol outlets to increase the impact of current adolescent pregnancy prevention programs., (© 2023. The Author(s).)

Objective: We investigated the association between the density of internal human migration, in the urban neighborhood, on frailty in the older adult population in Colombia. Methods: The data used in this study are from four Colombian population surveys. We analyzed 633 census tracts with a sample of 2,194 adults 60 years and over for frailty (measured using the Fried criteria). We considered the proportion of inhabitants in a census tract with a history of internal migration as the exposure variable considering three temporalities. For contextual forced migration, we identified two types: 5-year, and 1-year. Poisson multivariable regression models with two hierarchical levels (individual and census tracts) were estimated. Results: The prevalence of pre-fragile/frailty was 80.63% [CI 95%: 77.67, 83.28]. The prevalence ratio were significantly higher for the older adults who live in neighborhoods where a higher proportion of internal migrants reside. Conclusion: We conclude that older adults who lived in neighborhoods with a high proportion of internal migrants experience more frailty. Potential explanations are that neighborhoods with high internal migration could experience social (l increase in cultural heterogeneity, in the perception of insecurity, violence and physical conditions (pressure on local economies and services, leading elderly residents to compete for neighborhood resources), translated into social stress., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Rengifo-Reina, Barrientos-Gutiérrez, López-Olmedo, Sánchez and Diez Roux.)

This paper aims to identify typologies of Latin American cities based on socioeconomic urban environment patterns. We used census data from 371 urban agglomerations in 11 countries included in the SALURBAL project to identify socioeconomic typologies of cities in Latin America. Exploratory factor analysis was used to select a set of variables, and finite mixture modelling (FMM) was applied to identify clusters to define the typology of cities. Despite the heterogeneities among the Latin American cities, we also found similarities. By exploring intersections and contrasts among these clusters, it was possible to define five socioeconomic regional typology patterns. The main features of each one are low-education cities in Northeast Brazil; low-unemployment cities in Peru and Panama; high-education cities in Argentina, Chile, Colombia, Costa Rica, Nicaragua and Mexico; high female labor participation, with high primary education in Argentina and low primary education in Brazil; and low female labor participation and low education in Brazil, Colombia, El Salvador, Guatemala, and Mexico. Identifying clusters of cities with similar features underscores understanding of the urban social and economic development dynamics and assists in studying how urban features affect health, the environment, and sustainability., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Background: Epidemiologic studies have documented the associations between experiences of discrimination and adverse health outcomes. However, the relationship between discrimination and mortality, and the factors that may moderate this relationship are not well understood. This study examined whether lifetime and everyday discrimination were associated with all-cause and cardiovascular mortality and whether these associations differed by race and ethnicity, gender, and racial and ethnic residential segregation., Methods: The study included 1633 Black, 1403 Hispanic/Latino, and 2473 White participants aged 45 to 84 years from the Multi-Ethnic Study of Atherosclerosis, enrolled from 2000 to 2002 and followed across 5 exams (2002-2018). Discrimination was measured using the lifetime discrimination (major experiences of unfair treatment) and everyday discrimination (day-to-day experiences of unfair treatment) scales. Racial and ethnic residential segregation was measured using the Gi* statistic. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs, adjusting for sociodemographic characteristics, health behaviors, and clinical risk factors., Results: Each increase in reports of lifetime discrimination was associated with increased all-cause (HR, 1.06 [95% CI, 1.00-1.11]) and cardiovascular (HR, 1.15 [95% CI, 1.04-1.27]) mortality, adjusting for sociodemographic factors, health behaviors, and clinical risk factors. Associations between lifetime discrimination and cardiovascular mortality were observed across all racial and ethnic groups but were strongest and only statistically significant among Black participants (HR, 1.18 [95% CI, 1.02-1.37]). Additionally, in the fully adjusted model, each increase in reports of everyday discrimination was strongly associated with increased cardiovascular mortality (HR, 1.21 [95% CI, 1.03-1.43]). Associations for lifetime and everyday discrimination with all-cause and cardiovascular mortality were not modified by race and ethnicity, gender, or racial and ethnic residential segregation., Conclusions: These findings suggest that experiences of discrimination are associated with increased all-cause and cardiovascular mortality.

Background: Latin America and the Caribbean (LAC) is one of the most urbanized and violent regions worldwide. Homicides in youth (15-24 years old, yo) and young adults (25-39yo) are an especially pressing public health problem. Yet there is little research on how city characteristics relate to homicide rates in youth and young adults. We aimed to describe homicide rates among youth and young adults, as well as their association with socioeconomic and built environment factors across 315 cities in eight LAC countries., Methods: This is an ecological study. We estimated homicide rates in youth and young adults for the period 2010-2016. We investigated associations of homicide rates with sub-city education and GDP, Gini, density, landscape isolation, population and population growth using sex-stratified negative binomial models with city and sub-city level random intercepts, and country-level fixed effects., Findings: The mean sub-city homicide rate per 100,000 in persons aged 15-24 was 76.9 (SD = 95.9) in male and 6.7 (SD = 8.5) in female, and in persons aged 25-39 was 69.4 (SD = 68.9) in male and 6.0 (SD = 6.7) in female. Rates were higher in Brazil, Colombia, Mexico and El Salvador than in Argentina, Chile, Panama and Peru. There was significant variation in rates across cities and sub-cities, even after accounting for the country. In fully adjusted models, higher sub-city education scores and higher city GDP were associated with a lower homicide rate among male and female (rate ratios (RR) per SD higher value in male and female, respectively, 0.87 (CI 0.84-0.90) and 0.90 (CI 0.86-0.93) for education and 0.87 (CI 0.81-0.92) and 0.92 (CI 0.87-0.97) for GDP). A higher city Gini index was associated with higher homicide rates (RR 1.28 (CI 1.10-1.48) and 1.21 (CI 1.07-1.36) in male and female, respectively). Greater isolation da was also associated with higher homicide rates (RR 1.13 (CI 1.07-1.21) and 1.07 (CI 1.02-1.12) in male and female, respectively)., Interpretation: City and sub-city factors are associated with homicide rates. Improvements to education, social conditions and inequality and physical integration of cities may contribute to the reduction of homicides in the region., Funding: The Wellcome Trust [205177/Z/16/Z]., Competing Interests: None of the authors had any conflict of interest., (© 2023 The Author(s).)

Commuters in urban settlements are frequently exposed to high concentrations of air pollutants due to their proximity to mobile sources, making exposure to traffic-related air pollutants an important public health issue. Recent trends in urban transport towards zero- and low-tailpipe emission alternatives will likely result in decreased exposure to air pollutants. The TrUST (Urban transformations and health) study offers a unique opportunity to understand the impacts of a new cable car (TransMiCable) in underserved communities within Bogotá, Colombia. The aims of this study are to assess the personal exposure to fine particulate matter (PM 2.5 ), equivalent Black Carbon (eBC), and Carbon Monoxide (CO) in transport micro-environments and to estimate the inhaled dose per trip during mandatory multimodal trips before and after the implementation of the TransMiCable. We collected personal exposure data for Bus-Rapid-Transit (BRT) feeder buses, regular buses, informal transport, pedestrians, and TransMiCable. TransMiCable showed lower exposure concentration compared to BRT feeder and regular buses (PM 2.5 : 23.6 vs. 87.0 μg m -3 (P ≤ 0.001) and eBC: 5.2 vs. 28.2 μg m -3 (P ≤ 0.001), respectively). The mean concentration of PM 2.5 and eBC inside the TransMiCable cabins were 62 % and 82 % lower than the mean concentrations in buses. Furthermore, using a Monte Carlo simulation model, we found that including the TransMiCable as a feeder is related to a 54.4 μg/trip reduction in PM 2.5 inhaled dose and 35.8 μg/trip in eBC per trip. Those changes represent a 27 % and 34 % reduction in an inhaled dose per trip, respectively. Our results show that PM 2.5 , eBC, and CO inhaled dose for TransMiCable users is reduced due to lower exposure concentration inside its cabins and shorter travel time. The implementation of a cable car in Bogotá is likely to reduce air pollution exposure in transport micro-environments used by vulnerable populations living in semi-informal settlements., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Objective: The COVID-19 pandemic has exacerbated existing health disparities. To provide a historical perspective on health disparities for pandemic acute respiratory viruses, we conducted a scoping review of the public health literature of health disparities in influenza outcomes during the 1918, 1957, 1968, and 2009 influenza pandemics., Methods: We searched for articles examining socioeconomic or racial/ethnic disparities in any population, examining any influenza-related outcome (e.g., incidence, hospitalizations, mortality), during the 1918, 1957, 1968, and 2009 influenza pandemics. We conducted a structured search of English-written articles in PubMed supplemented by a snowball of articles meeting inclusion criteria., Results: A total of 29 articles met inclusion criteria, all but one focusing exclusively on the 1918 or 2009 pandemics. Individuals of low socioeconomic status, or living in low socioeconomic status areas, experienced higher incidence, hospitalizations, and mortality in the 1918 and 2009 pandemics. There were conflicting results regarding racial/ethnic disparities during the 1918 pandemic, with differences in magnitude and direction by outcome, potentially due to issues in data quality by race/ethnicity. Racial/ethnic minorities had generally higher incidence, mortality, and hospitalization rates in the 1957 and 2009 pandemics., Conclusion: Individuals of low socioeconomic status and racial/ethnic minorities have historically experienced worse influenza outcomes during pandemics. These historical patterns can inform current research to understand disparities in the ongoing COVID-19 pandemic and future pandemics., Competing Interests: The authors declare no conflict of interest., (© 2022 The Authors.)

Background: Mexico City approved new road safety policies in 2015, which included lower speed limits and higher fines for traffic offences. In 2019, economic fines were replaced by a point penalty system among other changes. This study evaluates these policies on road traffic collisions, injuries and deaths., Methods: Collisions data came from insurance collision claims (January 2015 to December 2019) and road traffic deaths from vital registrations (January 2013 to December 2019). We conducted an interrupted time series analysis for each outcome using negative binomial regression models with an offset of insured vehicles (collisions) or total population (deaths). Then, we classified the 16 municipalities in the city into enforcement and no-enforcement groups based on presence or absence of automated traffic enforcement devices and conducted a controlled interrupted time series analysis., Results: The 2015 road safety policies had no effect on total collisions and collisions resulting in injury but were associated with a 0.2% (95% CI -0.3 to 0.0) decline in the mortality trend. The 2019 policies had no effect on total collisions but were associated with a 1.5% increase in the trend of collisions resulting in injuries and with a 2.7% (95% CI 1.0 to 4.5) increase in the mortality trend. Postpolicy trends in enforcement versus no-enforcement municipalities were not significantly different., Conclusion: Policies that included high economic penalties for speeding and dangerous behaviours were effective in decreasing traffic mortality while removing economic penalties and replacing them with a point penalty system were associated with an increase in collisions, resulting in injury and mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Importance: Food insecurity disproportionately affects Black individuals in the US. Its association with coronary heart disease (CHD), heart failure (HF), and stroke is unclear., Objective: To evaluate the associations of economic food insecurity and proximity with unhealthy food options with risk of incident CHD, HF, and stroke and the role of diet quality and stress., Design, Setting, and Participants: This cohort study was a time-to-event analysis of 3024 Black adult participants in the Jackson Heart Study (JHS) without prevalent cardiovascular disease (CVD) at visit 1 (2000-2004). Data analysis was conducted from September 1, 2020, to November 30, 2021., Exposures: Economic food insecurity, defined as receiving food stamps or self-reported not enough money for groceries, and high frequency of unfavorable food stores (>2.5 unfavorable food stores [fast food restaurants, convenience stores] within 1 mile)., Main Outcomes and Measures: The main outcomes were incident CVD including incident CHD, stroke, and HF with preserved ejection fraction and with reduced ejection fraction (HFrEF). During a median follow-up of 13.8 (IQR, 12.8-14.6) years, the associations of measures of food inadequacy with incident CVD (CHD, stroke, and HF) were assessed using multivariable Cox proportional hazards regression models., Results: Among the 3024 study participants, the mean (SD) age was 54 (12) years, 1987 (66%) were women, 630 (21%) were economically food insecure, and 50% (by definition) had more than 2.5 unfavorable food stores within 1 mile. In analyses adjusted for cardiovascular risk and socioeconomic factors, economic food insecurity was associated with higher risk of incident CHD (hazard ratio [HR], 1.76; 95% CI, 1.06-2.91) and incident HFrEF (HR, 2.07; 95% CI, 1.16-3.70), but not stroke. These associations persisted after further adjustment for diet quality and perceived stress. In addition, economic food insecurity was associated with higher high-sensitivity C-reactive protein and renin concentrations. High frequency of unfavorable food stores was not associated with CHD, HF, or stroke., Conclusions and Relevance: The findings of this cohort study suggest that economic food insecurity, but not proximity to unhealthy food options, was associated with risk of incident CHD and HFrEF independent of socioeconomic factors, traditional cardiovascular risk factors, diet quality, perceived stress, and other health behaviors. Economic food insecurity was also associated with markers of inflammation and neurohormonal activation. Economic food insecurity may be a promising potential target for the prevention of CVD.

Levels of women's empowerment (WE) can contribute to differences in infant mortality rates (IMRs) across cities. We used a cross-sectional multilevel study to examine associations of WE with IMRs across 286 cities in seven Latin American countries. We estimated IMRs for 2014-2016 period and combined city socioeconomic indicators into factors reflecting living conditions and service provision. WE was operationalized: (1) in cities, by using scores for women's labor force participation (WLFP) and educational attainment among women derived from education and employment indicators disaggregated by sex; (2) in countries, by including a scale of enforcements of laws related to women's rights. We estimated adjusted percent differences in IMRs associated with higher WE scores across all cities and stratified by country GDP. We found substantial heterogeneity in IMRs and WE across cities. Higher WLFP was associated with lower IMRs. Higher women's educational attainment was associated with lower IMRs only in cities from countries with lower GDP. Poorer national enforcement of laws protecting women's rights was associated with higher IMRs in all countries. Women's empowerment could have positive implications for population health. Fostering women's socioeconomic development and girls' education should be part of strategies to reduce IMRs in cities of Global South., Competing Interests: Disclosure statement No potential conflict of interest was reported by the author(s).

Background: In Latin America, where climate change and rapid urbanization converge, non-optimal ambient temperatures contribute to excess mortality. However, little is known about area-level characteristics that confer vulnerability to temperature-related mortality., Objectives: Explore city-level socioeconomic and demographic characteristics associated with temperature-related mortality in Latin American cities., Methods: The dependent variables quantify city-specific associations between temperature and mortality: heat- and cold-related excess death fractions (EDF, or percentages of total deaths attributed to cold/hot temperatures), and the relative mortality risk (RR) associated with 1 °C difference in temperature in 325 cities during 2002-2015. Random effects meta-regressions were used to investigate whether EDFs and RRs associated with heat and cold varied by city-level characteristics, including population size, population density, built-up area, age-standardized mortality rate, poverty, living conditions, educational attainment, income inequality, and residential segregation by education level., Results: We find limited effect modification of cold-related mortality by city-level demographic and socioeconomic characteristics and several unexpected associations for heat-related mortality. For example, cities in the highest compared to the lowest tertile of income inequality have all-age cold-related excess mortality that is, on average, 3.45 percentage points higher (95% CI: 0.33, 6.56). Higher poverty and higher segregation were also associated with higher cold EDF among those 65 and older. Large, densely populated cities, and cities with high levels of poverty and income inequality experience smaller heat EDFs compared to smaller and less densely populated cities, and cities with little poverty and income inequality., Discussion: Evidence of effect modification of cold-related mortality in Latin American cities was limited, and unexpected patterns of modification of heat-related mortality were observed. Socioeconomic deprivation may impact cold-related mortality, particularly among the elderly. The findings of higher levels of poverty and income inequality associated with lower heat-related mortality deserve further investigation given the increasing importance of urban adaptation to climate change., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Gender inequality is high in Latin America (LA). Empowering girls and young women and reducing gender gaps has been proposed as a pathway to reduce adolescent pregnancy. We investigated the associations of urban measures of women's empowerment and gender inequality with adolescent birth rates (ABR) in 366 Latin American cities in nine countries., Methods: We created a gender inequality index (GII) and three Women Achievement scores reflecting domains of women's empowerment (employment, education, and health care access) using censuses, surveys, and political participation data at city and sub-city levels. We used 3-level negative binomial models (sub-city-city-countries) to assess the association between the GII and scores, with ABR while accounting for other city and sub-city characteristics., Results: We found within country heterogeneity in gender inequality and women's empowerment measures. The ABR was 4% higher for each 1 standard deviation (1-SD) higher GII (RR 1.04; 95%CI 1.01,1.06), 8% lower for each SD higher autonomy score (RR 0.92; 95%CI 0.86, 0.99), and 12% lower for each SD health care access score (RR 0.88; 95%CI 0.82,0.95) after adjustment for city level population size, population growth, homicide rates, and sub-city population educational attainment and living conditions scores., Conclusion: Our findings show the key role cities have in reducing ABR through the implementation of strategies that foster women's socioeconomic progress such as education, employment, and health care access., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: The burden of Alzheimer's disease (AD) and AD-related dementias (ADRD) is increasing nationally and globally, with disproportionate impacts on lower-income, lower education and systematically marginalised older adults. Presence of inequalities in neighbourhood factors (eg, social context, physical and built environments) may affect risk of cognitive decline and be key for intervening on AD/ADRD disparities at the population level. However, existing studies are limited by a dearth of longitudinal, detailed neighbourhood measures linked to rich, prospective cohort data. Our main objective is to identify patterns of neighbourhood change related to prevalence of-and disparities in-cognitive decline and dementia., Methods and Analyses: We describe the process of collecting, processing and linking extensive neighbourhood data to the Multi-Ethnic Study of Atherosclerosis (MESA), creating a 25+ years dataset. Within the MESA parent study, the MESA Neighborhoods and Aging cohort study will characterise dynamic, longitudinal neighbourhood social and built environment variables relevant to cognition for residential addresses of MESA participants. This includes administering new surveys, expanding residential address histories, calculating new measures derived from spatial data and implementing novel deep learning algorithms on street-level imagery. Applying novel statistical techniques, we will examine associations of neighbourhood environmental characteristics with cognition and clinically relevant AD/ADRD outcomes. We will investigate determinants of disparities in outcomes by socioeconomic position and race/ethnicity and assess the contribution of neighbourhood environments to these disparities. This project will provide new evidence about pathways between neighbourhood environments and cognitive outcomes, with implications for policies to support healthy ageing., Ethics and Dissemination: This project was approved by the University of Washington and Drexel University Institutional Review Boards (protocols #00009029 and #00014523, and #180900605). Data will be distributed through the MESA Coordinating Center. Findings will be disseminated in peer-reviewed scientific journals, briefs, presentations and on the participant website., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We investigated the association of urban landscape profiles with health and environmental outcomes, and whether those profiles are linked to environmental and health co-benefits. In this ecological study, we used data from 208 cities in 8 Latin American countries of the SALud URBana en América Latina (SALURBAL) project. Four urban landscape profiles were defined with metrics for the fragmentation, isolation, and shape of patches (contiguous area of urban development). Four environmental measures (lack of greenness, PM 2.5 , NO 2 , and carbon footprint), two cause-specific mortality rates (non-communicable diseases and unintentional injury mortality), and prevalence of three risk factors (hypertension, diabetes, and obesity) for adults were used as the main outcomes. We used linear regression models to evaluate the association of urban landscape profiles with environmental and health outcomes. In addition, we used finite mixture modeling to create co-benefit classes. Cities with the scattered pixels profile (low fragmentation, high isolation, and compact shaped patches) were most likely to have positive co-benefits. Profiles described as proximate stones (moderate fragmentation, moderate isolation, and irregular shape) and proximate inkblots (moderate-high fragmentation, moderate isolation, and complex shape) were most likely to have negative co-benefits. The contiguous large inkblots profile (low fragmentation, low isolation, and complex shape) was most likely to have mixed benefits., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest.

Paid sick leave provides workers with paid time off to receive COVID-19 vaccines and to recover from potential vaccine adverse effects. We hypothesized that US cities with paid sick leave would have higher COVID-19 vaccination coverage and narrower coverage disparities than those without such policies. Using county-level vaccination data and paid sick leave data from thirty-seven large US cities in 2021, we estimated the association between city-level paid sick leave policies and vaccination coverage in the working-age population and repeated the analysis using coverage in the population ages sixty-five and older as a negative control. We also examined associations by neighborhood social vulnerability. Cities with a paid sick leave policy had 17 percent higher vaccination coverage than cities without such a policy. We found stronger associations between paid sick leave and vaccination in the most socially vulnerable neighborhoods compared with the least socially vulnerable ones, and no association in the population ages sixty-five and older. Paid sick leave policies are associated with higher COVID-19 vaccination coverage and narrower coverage disparities. Increasing access to these policies may help increase vaccination and reduce inequities in coverage.

Background: Life expectancy in the United States has declined since 2014 but characterization of disparities within and across metropolitan areas of the country is lacking., Methods: Using census tract-level life expectancy from the 2010 to 2015 US Small-area Life Expectancy Estimates Project, we calculate 10 measures of total and income-based disparities in life expectancy at birth, age 25, and age 65 within and across 377 metropolitan statistical areas (MSAs) of the United States., Results: We found wide heterogeneity in disparities in life expectancy at birth across MSAs and regions: MSAs in the West show the narrowest disparities (absolute disparity: 8.7 years, relative disparity: 1.1), while MSAs in the South (absolute disparity: 9.1 years, relative disparity: 1.1) and Midwest (absolute disparity: 9.8 years, relative disparity: 1.1) have the widest life expectancy disparities. We also observed greater variability in life expectancy across MSAs for lower income census tracts (coefficient of variation [CoV] 3.7 for first vs. tenth decile of income) than for higher income census tracts (CoV 2.3). Finally, we found that a series of MSA-level variables, including larger MSAs and greater proportion college graduates, predicted wider life expectancy disparities for all age groups., Conclusions: Sociodemographic and policy factors likely help explain variation in life expectancy disparities within and across metro areas., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Testing for SARS-CoV-2 infection has been a key strategy to mitigate and control the COVID-19 pandemic. Wide spatial and racial/ethnic disparities in COVID-19 outcomes have emerged in US cities. Previous research has highlighted the role of unequal access to testing as a potential driver of these disparities. We described inequities in spatial accessibility to COVID-19 testing locations in 30 large US cities. We used location data from Castlight Health Inc corresponding to October 2021. We created an accessibility metric at the level of the census block group (CBG) based on the number of sites per population in a 15-minute walkshed around the centroid of each CBG. We also calculated spatial accessibility using only testing sites without restrictions, i.e., no requirement for an appointment or a physician order prior to testing. We measured the association between the social vulnerability index (SVI) and spatial accessibility using a multilevel negative binomial model with random city intercepts and random SVI slopes. Among the 27,195 CBG analyzed, 53% had at least one testing site within a 15-minute walkshed, and 36% had at least one site without restrictions. On average, a 1-decile increase in the SVI was associated with a 3% (95% Confidence Interval: 2% - 4%) lower accessibility. Spatial inequities were similar across various components of the SVI and for sites with no restrictions. Despite this general pattern, several cities had inverted inequity, i.e., better accessibility in more vulnerable areas, which indicates that some cities may be on the right track when it comes to promoting equity in COVID-19 testing. Testing is a key component of the strategy to mitigate transmission of SARS-CoV-2 and efforts should be made to improve accessibility to testing, particularly as new and more contagious variants become dominant., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Latin America has the second-highest adolescent birth rate (ABR) worldwide. Variation between urban and rural areas and evidence linking country development to ABR points towards upstream factors in the causal pathway. We investigated variation in ABR within and between cities, and whether different features of urban social environments are associated with ABR., Methods: We included 363 cities in 9 Latin American countries. We collected data on social environment at country, city and subcity levels and birth rates among adolescents (ages 15-19). We investigated variation in ABR within and between countries and cities along with associations between social environment and ABR by fitting three-level negative binomial models (subcities nested within cities nested within countries)., Results: The median subcity ABR was 58.5 per 1000 women 15-19 (IQR 43.0-75.3). We found significant variability in subcity ABR between countries and cities (37% of variance between countries and 47% between cities within countries). Higher homicide rates and greater population growth in cities were associated with higher ABR (rate ratio (RR) 1.09; 95% CI 1.06 to 1.12 and RR 1.02; 95% CI 1.00 to 1.04, per SD, respectively), while better living conditions and educational attainment in subcities were associated with lower ABR after accounting for other social environment characteristics (RR 0.95; 95% CI 0.92 to 0.98 and 0.78; 95% CI 0.76 to 0.79, per SD, respectively)., Conclusions: The large heterogeneity of ABR found within countries and cities highlights the key role urban areas have in developing local policies. Holistic interventions targeting education inequalities and living conditions are likely important to reducing ABR in cities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Cesarean section (CS) is a surgical procedure that, when medically justified, can help reduce maternal and infant morbidity and mortality. Worldwide CS rates (CSR) have been increasing; Latin America has rates that are among the highest in the world., Aim: Describe the variability of CSR across cities in Brazil, Colombia, Guatemala, Mexico, and Peru and examine the relationship of individual-level, sub-city, and city-level socioeconomic status (SES) with CSR., Methods: We used individual level data from vital statistics over the period 2014-2016 (delivery method, mother's age and education), census data to characterize sub-city SES and city GDP per capita from other sources compiled by the SALURBAL project. We fitted multilevel negative binomial regression models to estimate associations of SES with CSR., Results: 11,549,028 live births from 1,101 sub-city units in 305 cities of five countries were included. Overall, the CSR was 52%, with a wide range across sub-cities (13-91%). Of the total variability in sub-city CSRs, 67% was within countries. In fully adjusted model higher CSR was associated with higher maternal education [(PRR (CI95%) 0.81 (0.80-0.82) for lower educational level, 1.32 (1.31-1.33) for higher level (ref. medium category)], with higher maternal age [PRR (CI95%) 1.23 (1.22-1.24) for ages 20-34 years, and 1.48 (1.47-1.49) for ages ≥ 35 years (ref. ≤19 years], higher sub-city SES [(PRR (CI95%) 1.02 (1.01-1.03) per 1SD)], and higher city GDP per capita [(PRR (CI95%): 1.03 (1.00-1.07) for GDP between 10,500-18,000, and 1.09 (1.06-1.13) for GDP 18,000 or more (ref. <10,500)]., Conclusion: We found large variability in CSR across cities highlighting the potential role of local policies on CSR levels. Variability was associated in part with maternal and area education and GDP. Further research is needed to understand the reasons for this pattern and any policy implications it may have., Competing Interests: None., (© 2022 The Authors.)

Background: Transport walking has drawn growing interest due to its potential to increase levels of physical activities and reduce reliance on vehicles. While existing studies have compared built environment-health associations between Euclidean buffers and network buffers, no studies have systematically quantified the extent of bias in health effect estimates when exposures are measured in different buffers. Further, prior studies have done the comparisons focusing on only one or two geographic regions, limiting generalizability and restricting ability to test whether direction or magnitude of bias are different by context. This study aimed to quantify the degree of bias in associations between built environment exposures and transport walking when exposures were operationalized using Euclidean buffers rather than network buffers in diverse contexts., Methods: We performed a simulations study to systematically evaluate the degree of bias in associations between built environment exposures in Euclidean buffers and network buffers and transport walking, assuming network buffers more accurately captured true exposures. Additionally, we used empirical data from a multi-ethnic, multi-site cohort to compare associations between built environment amenities and walking for transport where built environment exposures were derived using Euclidean buffers versus network buffers., Results: Simulation results found that the bias induced by using Euclidean buffer models was consistently negative across the six study sites (ranging from -80% to -20%), suggesting built environment exposures measured using Euclidean buffers underestimate health effects on transport walking. Percent bias was uniformly smaller for the larger 5 km scale than the 1 km and 0.25 km spatial scales, independent of site or built environment categories. Empirical findings aligned with the simulation results: built environment-health associations were stronger for built environment exposures operationalized using network buffers than using Euclidean buffers., Conclusion: This study is the first to quantify the extent of bias in the magnitude of the associations between built environment exposures and transport walking when the former are measured in Euclidean buffers vs. network buffers, informing future research to carefully conceptualize appropriate distance-based buffer metrics in order to better approximate real geographic contexts. It also helps contextualize existing research in the field that used Euclidean buffers when that were the only option. Further, this study provides an example of the uncertain geographic context problem., (© 2022. The Author(s).)

Background Understanding the magnitude of cardiovascular disease (CVD) inequalities is the first step toward addressing them. The linkage of socioeconomic and clinical data in universal health care settings provides critical information to characterize CVD inequalities. Methods and Results We employed a prospective cohort design using electronic health records data from all residents of Catalonia aged 18+ between January and December of 2019 (N=6 332 228). We calculated age-adjusted sex-specific prevalence of 5 CVD risk factors (diabetes, hypertension, hyperlipidemia, obesity, and smoking), and 4 CVDs (coronary heart disease, cerebrovascular disease, atrial fibrillation, and heart failure). We categorized income into high, moderate, low, and very low according to individual income (tied to prescription copayments) and receipt of welfare support. We found large inequalities in CVD and CVD risk factors among men and women. CVD risk factors with the largest inequalities were diabetes, smoking, and obesity, with prevalence rates 2- or 3-fold higher for those with very low (versus high) income. CVDs with the largest inequalities were cerebrovascular disease and heart failure, with prevalence rates 2 to 4 times higher for men and women with very low (versus high) income. Inequalities varied by age, peaking at midlife (30-50 years) for most diseases, while decreasing gradually with age for smoking. Conclusions We found wide and heterogeneous inequalities by income in 5 CVD risk factors and 4 CVD. Our findings in a region with a high-quality public health care system and universal coverage stress that strong equity-promoting policies are necessary to reduce disparities in CVD.

Objectives: To evaluate variability in life expectancy at birth in small areas, describe the spatial pattern of life expectancy, and examine associations between small-area socioeconomic characteristics and life expectancy in a mid-sized city of a middle-income country., Design: Cross-sectional, using data from death registries (2015-2018) and socioeconomic characteristics data from the 2010 national population census., Participants/setting: 40 898 death records in 99 small areas of the city of Córdoba, Argentina. We summarised variability in life expectancy at birth by using the difference between the 90th and 10th percentile of the distribution of life expectancy across small areas (P90-P10 gap) and evaluated associations with small-area socioeconomic characteristics by calculating a Slope Index of Inequality in linear regression., Primary Outcome: Life expectancy at birth., Results: The median life expectancy at birth was 80.3 years in women (P90-P10 gap=3.2 years) and 75.1 years in men (P90-P10 gap=4.6 years). We found higher life expectancies in the core and northwest parts of the city, especially among women. We found positive associations between life expectancy and better small-area socioeconomic characteristics, especially among men. Mean differences in life expectancy between the highest versus the lowest decile of area characteristics in men (women) were 3.03 (2.58), 3.52 (2.56) and 2.97 (2.31) years for % adults with high school education or above, % persons aged 15-17 attending school, and % households with water inside the dwelling, respectively. Lower values of % overcrowded households and unemployment rate were associated with longer life expectancy: mean differences comparing the lowest versus the highest decile were 3.03 and 2.73 in men and 2.57 and 2.34 years in women, respectively., Conclusion: Life expectancy is substantially heterogeneous and patterned by socioeconomic characteristics in a mid-sized city of a middle-income country, suggesting that small-area inequities in life expectancy are not limited to large cities or high-income countries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Extreme temperatures may lead to adverse pregnancy and birth outcomes, including low birthweight. Studies on the impact of temperature on birthweight have been inconclusive due to methodological challenges related to operationalizing temperature exposure, the definitions of exposure windows, accounting for gestational age, and a limited geographic scope., Methods: We combined data on individual-level term live births (N≈15 million births) from urban areas in Brazil, Chile, and Mexico from 2010 to 2015 from the SALURBAL study (Urban Health in Latin America) with high-resolution daily air temperature data and computed average ambient temperature for every month of gestation for each newborn. Associations between full-term birthweight and average temperature during gestation were analyzed using multi-level distributed lag non-linear models that adjusted for newborn's sex, season of conception, and calendar year of child's birth; controlled for maternal age, education, partnership status, presence of previous births, and climate zone; and included a random term for the sub-city of mother's residence., Findings: Higher temperatures during the entire gestation are associated with lower birthweight, particularly in Mexico and Brazil. The cumulative effect of temperature on birthweight is mostly driven by exposure to higher temperatures during months 7-9 of gestation. Higher maternal education can attenuate the temperature-birthweight associations., Interpretation: Our work shows that climate-health impacts are likely to be context- and place-specific and warrants research on temperature and birthweight in diverse climates to adequately anticipate global climate change. Given the high societal cost of suboptimal birthweight, public health efforts should be aimed at diminishing the detrimental effect of higher temperatures on birthweight., Funding: The Wellcome Trust., (Copyright © 2022. Published by Elsevier Ltd.)

We examined associations of individual-, neighborhood- and city-level education -as proxies of SES at different levels-, with diabetes, hypertension, obesity, smoking and binge drinking (non-communicable disease risk factors -NCD/RF) among Argentinian adults. We estimated mixed models based on 21,415 individuals from the 2013 National Survey of Risk Factors, living in 2,698 neighborhoods and 33 cities. Gradients by individual-level education differed by gender and NCD/RF, and some were modified by city education. In addition, we identified contextual effects of neighborhood and city education on some NCD/RF. Urban efforts to tackle NCD/RF in Argentina should be context- and gender-sensitive, and mainly focused on socially disadvantaged groups., Competing Interests: Declaration of competing interest None., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Differences in vaccination coverage can perpetuate coronavirus disease 2019 (COVID-19) disparities. We explored the association between neighborhood-level social vulnerability and COVID-19 vaccination coverage in 16 large US cities from the beginning of the vaccination campaign in December 2020 through September 2021. We calculated the proportion of fully vaccinated adults in 866 zip code tabulation areas (ZCTAs) of 16 large US cities: Long Beach, Los Angeles, Oakland, San Diego, San Francisco, and San Jose, all in California; Chicago, Illinois; Indianapolis, Indiana; Minneapolis, Minnesota; New York, New York; Philadelphia, Pennsylvania; and Austin, Dallas, Fort Worth, Houston, and San Antonio, all in Texas. We computed absolute and relative total and Social Vulnerability Index-related inequities by city. COVID-19 vaccination coverage was 0.75 times (95% confidence interval: 0.69, 0.81) or 16 percentage points (95% confidence interval: 12.1, 20.3) lower in neighborhoods with the highest social vulnerability as compared with those with the lowest. These inequities were heterogeneous, with cities in the West generally displaying narrower inequities in both the absolute and relative scales. The Social Vulnerability Index domains of socioeconomic status and of household composition and disability showed the strongest associations with vaccination coverage. Inequities in COVID-19 vaccinations hamper efforts to achieve health equity, as they mirror and could lead to even wider inequities in other COVID-19 outcomes., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Background: Understanding how urban environments influence people's health, especially as individuals age, can help identify ways to improve health in the rapidly urbanizing and rapidly aging populations., Objectives: To investigate the association between age and self-reported health (SRH) in adults living in Latin-American cities and whether gender and city-level socioeconomic characteristics modify this association., Methods: Cross-sectional analyses of 71,541 adults aged 25-97 years, from 114 cities in 6 countries (Argentina, Brazil, Colombia, Chile, El Salvador, and Guatemala), as part of the Salud Urbana en America Latina (SALURBAL) Project. We used individual-level age, gender, education, and self-reported health (SRH) data from harmonized health surveys. As proxies for socioeconomic environment we used a city-level socioeconomic index (SEI) calculated from census data, and gross domestic product (GDP) per-capita. Multilevel Poisson models with a robust variance were used to estimate relative risks (RR), with individuals nested in cities and binary SRH (poor SHR vs. good SRH) as the outcome. We examined effect modification by gender and city-level socioeconomic indicators., Results: Overall, 31.4% of the sample reported poor SRH. After adjusting for individual-level education, men had a lower risk of poor SRH (RR = 0.76; CI 0.73-0.78) compared to women, and gender modified the association between age and poor SRH (p-value of interaction < 0.001). In gender stratified models, the association between older age and poor SRH was more pronounced in men than in women, and in those aged 25-65 than among those 65+ (RR/10 years = 1.38 vs. 1.10 for men, and RR/10 years = 1.29 vs. 1.02 for women). Living in cities with higher SEI or higher GDP per-capita was associated with a lower risk of poor SRH. GDP per-capita modified the association between age (25-65) and SRH in men and women, with SEI the interaction was less clear., Conclusions: Across cities in Latin America, aging impact on health is significant among middle-aged adults, and among men. In both genders, cities with lower SEI or lower GDP per-capita were associated with poor SRH. More research is needed to better understand gender inequalities and how city socioeconomic environments, represented by different indicators, modify exposures and vulnerabilities associated with aging., (© 2022. The Author(s).)

Climate change and urbanization are rapidly increasing human exposure to extreme ambient temperatures, yet few studies have examined temperature and mortality in Latin America. We conducted a nonlinear, distributed-lag, longitudinal analysis of daily ambient temperatures and mortality among 326 Latin American cities between 2002 and 2015. We observed 15,431,532 deaths among ≈2.9 billion person-years of risk. The excess death fraction of total deaths was 0.67% (95% confidence interval (CI) 0.58-0.74%) for heat-related deaths and 5.09% (95% CI 4.64-5.47%) for cold-related deaths. The relative risk of death was 1.057 (95% CI 1.046-1.067%) per 1 °C higher temperature during extreme heat and 1.034 (95% CI 1.028-1.040%) per 1 °C lower temperature during extreme cold. In Latin American cities, a substantial proportion of deaths is attributable to nonoptimal ambient temperatures. Marginal increases in observed hot temperatures are associated with steep increases in mortality risk. These risks were strongest among older adults and for cardiovascular and respiratory deaths., (© 2022. The Author(s).)

Background: Despite improvements in population health, marked racial and ethnic disparities in longevity and cardiovascular disease (CVD) mortality persist. This study aimed to describe risks for all-cause and CVD mortality by race and ethnicity, before and after accounting for socioeconomic status (SES) and other factors, in the MESA study (Multi-Ethnic Study of Atherosclerosis)., Methods: MESA recruited 6814 US adults, 45 to 84 years of age, free of clinical CVD at baseline, including Black, White, Hispanic, and Chinese individuals (2000-2002). Using Cox proportional hazards modeling with time-updated covariates, we evaluated the association of self-reported race and ethnicity with all-cause and adjudicated CVD mortality, with progressive adjustments for age and sex, SES (neighborhood SES, income, education, and health insurance), lifestyle and psychosocial risk factors, clinical risk factors, and immigration history., Results: During a median of 15.8 years of follow-up, 22.8% of participants (n=1552) died, of which 5.3% (n=364) died of CVD. After adjusting for age and sex, Black participants had a 34% higher mortality hazard (hazard ratio [HR], 1.34 [95% CI, 1.19-1.51]), Chinese participants had a 21% lower mortality hazard (HR, 0.79 [95% CI, 0.66-0.95]), and there was no mortality difference in Hispanic participants (HR, 0.99 [95% CI, 0.86-1.14]) compared with White participants. After adjusting for SES, the mortality HR for Black participants compared with White participants was reduced (HR, 1.16 [95% CI, 1.01-1.34]) but still statistically significant. With adjustment for SES, the mortality hazards for Chinese and Hispanic participants also decreased in comparison with White participants. After further adjustment for additional risk factors and immigration history, Hispanic participants (HR, 0.77 [95% CI, 0.63-0.94]) had a lower mortality risk than White participants, and hazard ratios for Black participants (HR, 1.08 [95% CI, 0.92-1.26]) and Chinese participants (HR, 0.81 [95% CI, 0.60-1.08]) were not significantly different from those of White participants. Similar trends were seen for CVD mortality, although the age- and sex-adjusted HR for CVD mortality for Black participants compared with White participants was greater than all-cause mortality (HR, 1.72 [95% CI, 1.34-2.21] compared with HR, 1.34 [95% CI, 1.19-1.51])., Conclusions: These results highlight persistent racial and ethnic differences in overall and CVD mortality, largely attributable to social determinants of health, and support the need to identify and act on systemic factors that shape differences in health across racial and ethnic groups.

Urban scaling is a framework that describes how city-level characteristics scale with variations in city size. This scoping review mapped the existing evidence on the urban scaling of health outcomes to identify gaps and inform future research. Using a structured search strategy, we identified and reviewed a total of 102 studies, a majority set in high-income countries using diverse city definitions. We found several historical studies that examined the dynamic relationships between city size and mortality occurring during the nineteenth and early twentieth centuries. In more recent years, we documented heterogeneity in the relation between city size and health. Measles and influenza are influenced by city size in conjunction with other factors like geographic proximity, while STIs, HIV, and dengue tend to occur more frequently in larger cities. NCDs showed a heterogeneous pattern that depends on the specific outcome and context. Homicides and other crimes are more common in larger cities, suicides are more common in smaller cities, and traffic-related injuries show a less clear pattern that differs by context and type of injury. Future research should aim to understand the consequences of urban growth on health outcomes in low- and middle-income countries, capitalize on longitudinal designs, systematically adjust for covariates, and examine the implications of using different city definitions., (© 2022. The Author(s).)

Objectives. To describe the creation of an interactive dashboard to advance the understanding of the COVID-19 pandemic from an equity and urban health perspective across 30 large US cities that are members of the Big Cities Health Coalition (BCHC). Methods. We leveraged the Drexel‒BCHC partnership to define the objectives and audience for the dashboard and developed an equity framework to conceptualize COVID-19 inequities across social groups, neighborhoods, and cities. We compiled data on COVID-19 trends and inequities by race/ethnicity, neighborhood, and city, along with neighborhood- and city-level demographic and socioeconomic characteristics, and built an interactive dashboard and Web platform to allow interactive comparisons of these inequities across cities. Results. We launched the dashboard on January 21, 2021, and conducted several dissemination activities. As of September 2021, the dashboard included data on COVID-19 trends for the 30 cities, on inequities by race/ethnicity in 21 cities, and on inequities by neighborhood in 15 cities. Conclusions. This dashboard allows public health practitioners to contextualize racial/ethnic and spatial inequities in COVID-19 across large US cities, providing valuable insights for policymakers. ( Am J Public Health . 2022;112(6):904-912. https://doi.org/10.2105/AJPH.2021.306708).

Vegetation may influence asthma exacerbation through effects on aeroallergens, localized climates, air pollution, or children's behaviors and stress levels. We investigated the association between residential vegetation and asthma exacerbation by conducting a matched case-control study based on electronic health records of asthma patients, from the Children's Hospital of Philadelphia (CHOP). Our study included 17,639 exacerbation case events and 34,681 controls selected from non-exacerbation clinical visits for asthma, matched to cases by age, sex, race/ethnicity, public payment source, and residential proximity to the CHOP main campus ED and hospital. Overall greenness, tree canopy, grass/shrub cover, and impervious surface were assessed near children's homes (250 m) using satellite imagery and high-resolution landcover data. We used generalized estimating equations to estimate odds ratios (OR) and 95% confidence intervals (CI) for associations between each vegetation/landcover measure and asthma exacerbation, with adjustment for seasonal and sociodemographic factors-for all cases, and for cases defined by diagnosis setting and exacerbation frequency. Lower odds of asthma exacerbation were observed in association with greater levels of tree canopy near the home, but only for children who experienced multiple exacerbations in a year (OR = 0.94 per 10.2% greater tree canopy coverage, 95% CI = 0.90-0.99). Our findings suggest possible protection for asthma patients from tree canopy, but differing results by case frequency suggest that potential benefits may be specific to certain subpopulations of asthmatic children., (© 2022. The New York Academy of Medicine.)

Objectives: To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption., Design: We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing., Setting: We estimated policy effects in scenarios representing two stages of the 'social transition' in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile., Participants: A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico., Results: A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario., Conclusions: Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.

Racial health inequities may be partially explained by area-level factors such as residential segregation. In this cross-sectional study, using a large, multiracial, representative sample of Brazilian adults (n = 37,009 individuals in the 27 state capitals; National Health Survey (Pesquisa Nacional de Saúde), 2013), we investigated 1) whether individual-level self-rated health (SRH) (fair or poor vs. good or better) varies by race (self-declared White, Brown, or Black) and 2) whether city-level economic or racial residential segregation (using dissimilarity index values in tertiles: low, medium, and high) interacts with race, increasing racial inequities in SRH. Prevalence of fair or poor SRH was 31.5% (Black, Brown, and White people: 36.4%, 34.0%, and 27.3%, respectively). Marginal standardization based on multilevel logistic regression models, adjusted for age, gender, and education, showed that Black and Brown people had, respectively, 20% and 10% higher prevalence of fair or poor SRH than did White people. Furthermore, residential segregation interacted with race such that the more segregated a city, the greater the racial gap among Black, Brown, and White people in fair or poor SRH for both income and race segregation. Policies to reduce racial inequities may need to address residential segregation and its consequences for health., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Low socioeconomic status (SES) and living in a disadvantaged neighborhood are associated with poor cardiovascular health. Multiple lines of evidence have linked DNA methylation to both cardiovascular risk factors and social disadvantage indicators. However, limited research has investigated the role of DNA methylation in mediating the associations of individual- and neighborhood-level disadvantage with multiple cardiovascular risk factors in large, multi-ethnic, population-based cohorts. We examined whether disadvantage at the individual level (childhood and adult SES) and neighborhood level (summary neighborhood SES as assessed by Census data and social environment as assessed by perceptions of aesthetic quality, safety, and social cohesion) were associated with 11 cardiovascular risk factors including measures of obesity, diabetes, lipids, and hypertension in 1,154 participants from the Multi-Ethnic Study of Atherosclerosis (MESA). For significant associations, we conducted epigenome-wide mediation analysis to identify methylation sites mediating the relationship between individual/neighborhood disadvantage and cardiovascular risk factors using the JT-Comp method that assesses sparse mediation effects under a composite null hypothesis. In models adjusting for age, sex, race/ethnicity, smoking, medication use, and genetic principal components of ancestry, epigenetic mediation was detected for the associations of adult SES with body mass index (BMI), insulin, and high-density lipoprotein cholesterol (HDL-C), as well as for the association between neighborhood socioeconomic disadvantage and HDL-C at FDR q < 0.05. The 410 CpG mediators identified for the SES-BMI association were enriched for CpGs associated with gene expression (expression quantitative trait methylation loci, or eQTMs), and corresponding genes were enriched in antigen processing and presentation pathways. For cardiovascular risk factors other than BMI, most of the epigenetic mediators lost significance after controlling for BMI. However, 43 methylation sites showed evidence of mediating the neighborhood socioeconomic disadvantage and HDL-C association after BMI adjustment. The identified mediators were enriched for eQTMs, and corresponding genes were enriched in inflammatory and apoptotic pathways. Our findings support the hypothesis that DNA methylation acts as a mediator between individual- and neighborhood-level disadvantage and cardiovascular risk factors, and shed light on the potential underlying epigenetic pathways. Future studies are needed to fully elucidate the biological mechanisms that link social disadvantage to poor cardiovascular health., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wang, Zhao, Ammous, Song, Du, Shang, Ratliff, Moore, Kelly, Needham, Diez Roux, Liu, Butler, Kardia, Mukherjee, Zhou and Smith.)

Objectives: High ambient temperatures may contribute to acute asthma exacerbation, a leading cause of morbidity in children. We quantified associations between hot-season ambient temperatures and asthma exacerbation in children ages 0-18 years in Philadelphia, PA., Methods: We created a time series of daily counts of clinical encounters for asthma exacerbation at the Children's Hospital of Philadelphia linked with daily meteorological data, June-August of 2011-2016. We estimated associations between mean daily temperature (up to a 5-day lag) and asthma exacerbation using generalised quasi-Poisson distributed models, adjusted for seasonal and long-term trends, day of the week, mean relative humidity,and US holiday. In secondary analyses, we ran models with adjustment for aeroallergens, air pollutants and respiratory virus counts. We quantified overall associations, and estimates stratified by encounter location (outpatient, emergency department, inpatient), sociodemographics and comorbidities., Results: The analysis included 7637 asthma exacerbation events. High mean daily temperatures that occurred 5 days before the index date were associated with higher rates of exacerbation (rate ratio (RR) comparing 33°C-13.1°C days: 1.37, 95% CI 1.04 to 1.82). Associations were most substantial for children ages 2 to <5 years and for Hispanic and non-Hispanic black children. Adjustment for air pollutants, aeroallergens and respiratory virus counts did not substantially change RR estimates., Conclusions: This research contributes to evidence that ambient heat is associated with higher rates of asthma exacerbation in children. Further work is needed to explore the mechanisms underlying these associations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

In a context where epidemiologic research has been heavily influenced by a biomedical and individualistic approach, the naming of "social epidemiology" allowed explicit emphasis on the social production of disease as a powerful explanatory paradigm and as critically important for interventions to improve population health. This review briefly highlights key substantive areas of focus in social epidemiology over the past 30 years, reflects on major advances and insights, and identifies challenges and possible future directions. Future opportunities for social epidemiology include grounding research in theoretically based and systemic conceptual models of the fundamental social drivers of health; implementing a scientifically rigorous yet realistic approach to drawing conclusions about social causes; using complementary methods to generate valid explanations and identify effective actions; leveraging the power of harmonization, replication, and big data; extending interdisciplinarity and diversity; advancing emerging critical approaches to understanding the health impacts of systemic racism and its policy implications; going global; and embracing a broad approach to generating socially useful research.

Objectives: To describe the association between population size, population growth and opioid overdose deaths-overall and by type of opioid-in US commuting zones (CZs) in three periods between 2005 and 2017., Settings: 741 CZs covering the entirety of the US CZs are aggregations of counties based on commuting patterns that reflect local economies., Participants: We used mortality data at the county level from 2005 to 2017 from the National Center for Health Statistics., Outcome: Opioid overdose deaths were defined using underlying and contributory causes of death codes from the International Classification of Diseases, 10th revision (ICD-10). We used the underlying cause of death to identify all drug poisoning deaths. Contributory cause of death was used to classify opioid overdose deaths according to the three major types of opioid, that is, prescription opioids, heroin and synthetic opioids other than methadone., Results: Opioid overdose deaths were disproportionally higher in largely populated CZs. A CZ with 1.0% larger population had 1.10%, 1.10%, and 1.16% higher opioid death count in 2005-2009, 2010-2014, and 2015-2017, respectively. This pattern was largely driven by a high number of deaths involving heroin and synthetic opioids, particularly in 2015-2017. Population growth over time was associated with lower age-adjusted opioid overdose mortality rate: a 1.0% increase in population over time was associated with 1.4% (95% CI: -2.8% to 0.1%), 4.5% (95% CI: -5.8% to -3.2%), and 1.2% (95% CI: -4.2% to 1.8%) lower opioid overdose mortality in 2005-2009, 2010-2014, and 2015-2017, respectively. The association between positive population growth and lower opioid mortality rates was stronger in larger CZs., Conclusions: Opioid overdose mortality in the USA was disproportionately higher in mid-sized and large CZs, particularly those affected by declines in population over time, regardless of the region where they are located., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Indoor dining is one of the potential drivers of COVID-19 transmission. We used the heterogeneity among state government preemption of city indoor dining closures to estimate the impact of keeping indoor dining closed on COVID-19 incidence., Methods: We obtained case rates and city or state reopening dates from March to October 2020 in 11 US cities. We categorized cities as treatment cities that were allowed by the state to reopen but kept indoor dining closed or comparison cities that would have kept indoor dining closed but that were preempted by their state and had to reopen indoor dining. We modeled associations using a difference-in-difference approach and an event study specification. We ran negative binomial regression models, with city-day as the unit of analysis, city population as an offset, and controlling for time-varying nonpharmaceutical interventions, as well as city and time fixed effects in sensitivity analysis and the event study specification., Results: Keeping indoor dining closed was associated with a 55% (IRR = 0.45; 95% confidence intervals = 0.21, 0.99) decline in the new COVID-19 case rate over 6 weeks compared with cities that reopened indoor dining, and these results were consistent after testing alternative modeling strategies., Conclusions: Keeping indoor dining closed may be directly or indirectly associated with reductions in COVID-19 spread. Evidence of the relationship between indoor dining and COVID-19 case rates can inform policies to restrict indoor dining as a tailored strategy to reduce COVID-19 incidence. See video abstract at, http://links.lww.com/EDE/B902., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)