Neighborhoods and obesity in later life

Objectives. We examined the influence of neighborhood environment on the weight status of adults 55 years and older.Methods. We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability.Results. When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese.Conclusions. The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.Over the past few decades the prevalence of obesity has been rising for men and women across all age groups, including the elderly.¹ For example, in 2001 to 2002 in the United States, about 1 in 3 adults 60 years or older was obese.² This trend raises concerns because excess weight is associated with a number of chronic health conditions, including diabetes, high blood pressure, asthma, and arthritis.³ Moreover, obesity can have very important implications for publicly financed health care.⁴ Recent research suggests that a number of demographic, socioeconomic, and family factors⁵ influence obesity, but the role of the neighborhood context has not been fully explored.Excess weight results from an energy imbalance in which caloric intake exceeds energy expenditures, the latter closely related to physical activity. The neighborhood environment may influence energy intake (through its influence on food availability⁶) and energy expenditure (by facilitating or impeding physical activity). For example, the presence of supermarkets in the neighborhood is associated with higher fruit and vegetable intake,⁷ whereas eating at fast-food restaurants is associated with a high-fat diet and higher body mass index (BMI; weight in kilograms divided by height in meters squared).⁸ In terms of physical activity, individuals living in neighborhoods with less crime,^9–13 higher land-use mix,¹⁴ higher street connectivity,^11,14,15 higher residential density,^11,14 a greater number of destinations,^9,16 better aesthetics,^9,10,17 and sidewalks^10,12,17,18 tend to walk more often.^19,20Only a handful of studies linking neighborhood features to late-life obesity have focused on older adults.^{11,13,16,21–23} National studies are particularly lacking for the elderly. Yet evidence from national studies of adults of all ages suggests plausible connections between obesity and neighborhood factors. Using the 1990 to 1994 waves of the National Health Interview Survey, for example, Boardman et al.²⁴ found that adults residing in neighborhoods with a high concentration of poverty and in neighborhoods with a high percentage of Blacks were more likely to be obese. In another study, Robert and Reither²⁵ found that higher community socioeconomic disadvantage was related to higher BMI among women but not among men. Because these studies had very limited characterizations of the neighborhoods, the mechanism through which poor neighborhoods result in obesity remains unclear. It could be, for instance, that poor neighborhoods tend to have fewer supermarkets^26–28 and more-limited access to places for physical activity.^29,30Using a large, nationally representative survey, we examined the relationship between the economic, built, and social environments and weight status among men and women 55 years and older. We included 8 previously validated neighborhood scales reflecting neighborhood safety and segregation, concentration of immigrants, air pollution, residential stability, connectivity, density or access, and high and low neighborhood socioeconomic status.³¹ We modeled both obesity and overweight status by using multilevel modeling techniques in which we controlled for detailed individual- and family-level confounders.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

Alcohol advertising at Boston subway stations: an assessment of exposure by race and socioeconomic status

Objectives. We investigated the frequency of alcohol ads at all 113 subway and streetcar stations in Boston and the patterns of community exposure stratified by race, socioeconomic status, and age.Methods. We assessed the extent of alcohol advertising at each station in May 2009. We measured gross impressions and gross rating points (GRPs) for the entire Greater Boston population and for Boston public school student commuters. We compared the frequency of alcohol advertising between neighborhoods with differing demographics.Results. For the Greater Boston population, alcohol advertising at subway stations generated 109 GRPs on a typical day. For Boston public school students in grades 5 to 12, alcohol advertising at stations generated 134 GRPs. Advertising at stations in low-poverty neighborhoods generated 14.1 GRPs and at stations in high-poverty areas, 63.6 GRPs.Conclusions. Alcohol ads reach the equivalent of every adult in the Greater Boston region and the equivalent of every 5th- to 12th-grade public school student each day. More alcohol ads were displayed in stations in neighborhoods with high poverty rates than in stations in neighborhoods with low poverty rates.Excessive alcohol use is the third-leading lifestyle-related cause of death in the United States.¹ Immediate health risks include unintentional injuries,² violence,^2,3 risky sexual behaviors,^4,5 miscarriage and stillbirth among pregnant women,^6,7 fetal alcohol syndrome,⁷ and alcohol poisoning.⁸ Long-term health risks include neurological,^9,10 cardiovascular,^11,12 and psychiatric problems,¹³ as well as an increased risk of cancer,^12,14 liver disease,^12,15,16 and pancreatitis.^12,17,18 Excessive alcohol use is also linked to a variety of social problems, including increased unemployment¹⁹ and frequency of violent crime and incarceration.^20,21 Drinking among underage youths is increasing.^22–25 Excessive alcohol use also has economic consequences. Alcohol-related health care utilization (e.g., motor vehicle crashes, fires), productivity losses, social welfare (e.g., food stamps), and criminal justice cost the United States an estimated $184.6 billion in 1998 alone.^12,26Alcohol advertising has historically been linked to increased consumption of alcohol in youths,^25,27–31 and a more recent study also shows an increase in consumption by adults.³² These data come from studies of advertising in a variety of media, including television, music video, public transit, and outdoor advertising.^25–31 Alcohol is disproportionately advertised in low-income neighborhoods^33,34 and in neighborhoods with a high proportion of racial and ethnic minorities.^32,34–36Studies have shown that people of color experience poorer health outcomes and shorter life expectancies than do Whites.³⁷ Individuals of lower socioeconomic status also have been found to have higher morbidity and mortality and more risk factors for heart disease and stroke than do people of higher socioeconomic status.³⁸ Minorities are more likely to live in poverty, which exacerbates the negative consequences of alcohol use.³⁹ Because racial and ethnic minorities and individuals of lower socioeconomic status are at a higher risk for poor health and have been identified as targets of alcohol advertising, it is critical that advertising policies change to protect these disadvantaged groups. Hackbarth et al. suggest that reducing alcohol consumption among disadvantaged groups through community intervention, such as banning alcohol advertising, would be one way to eliminate such health disparities.³⁶In 2007 Kwate et al. determined that Black neighborhoods in New York City had more advertising space than White neighborhoods and that these spaces were disproportionately used to market alcohol and tobacco products.³⁵ However, they did not find a significant relationship between median income and ad density, which suggests that relative affluence did not protect Black neighborhoods from targeted outdoor advertising.Advertising on public transportation has received little attention in the literature. In 2007, a report issued by the Marin Institute documented the advertising practices of 20 public transit agencies nationwide. The report found that 2 major cities, Boston, Massachusetts and New York City, lagged far behind other cities that had policies in place to protect children from alcohol advertising.²⁵ Chicago, Illinois; Los Angeles, California; San Francisco, California; Washington, DC; and other places explicitly prohibit alcohol advertising on public transit systems. For example, San Francisco imposes a $5000 per day fine for violating advertising policies.²⁵ By contrast, the Massachusetts Bay Transit Authority (MBTA), which serves the Boston area, has no such restrictions against alcohol advertising, although it claims to prohibit all “adult-oriented goods and services.” The MBTA bans advertising that features tobacco, violence, or nudity because they are considered inappropriate for viewing by minors.²⁵ It is disturbing that one of the largest cities in the United States has not yet adopted stricter policies to protect its riders from potentially harmful alcohol ads.In 2009, Nyborn et al. studied the frequency of alcohol advertising on MBTA train cars and found that alcohol advertisers were able to reach the equivalent of nearly half of all transit passengers each day.⁴⁰ These data showed that roughly 315 000 people, or 11% of the entire adult population in the greater Boston area (Suffolk, Middlesex, and Norfolk counties; total 2008 population = 2 841 374⁴¹) may be exposed to alcohol ads on the MBTA train lines alone. However, that study focused on ads on moving trains and did not consider the frequency of alcohol ads at train stations and how this frequency might differ between neighborhoods. We expanded the focus to include train stations to investigate whether alcohol advertising targeted particular socioeconomic or racial/ethnic groups.We aimed to (1) quantify exposure to alcohol advertising at MBTA train stations among adults in the greater Boston area and among Boston public school students in grades 5 to 12 and (2) compare the frequency of alcohol ads in different MBTA train stations to determine whether minority or poor populations were disproportionately exposed.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Neighborhood social disorganization and the acquisition of trichomoniasis among young adults in the United States

Objectives. We examined relationships between neighborhood social disorganization and trichomoniasis among young US adults.Methods. We employed multilevel logistic regression modeling with secondary data from wave III of the National Longitudinal Study of Adolescent Health (2001–2002). The dependent variable—trichomoniasis—was measured via urine testing. The measures for neighborhood social disorganization were derived from the 2000 US Census—racial and ethnic composition, concentrated poverty, and residential instability. The sample comprised 11 370 individuals across 4912 neighborhoods.Results. Trichomoniasis was more likely in neighborhoods with higher concentrations of Black residents (adjusted odds ratio [AOR] = 1.16; 95% confidence interval [CI] = 1.03, 1.30). However, this association was mediated by neighborhood concentrated poverty. Furthermore, young adults who lived in neighborhoods with higher concentrations of poverty were significantly more likely to have trichomoniasis (AOR = 1.25; 95% CI = 1.07, 1.46). Neither immigrant concentration nor residential instability was significantly associated with trichomoniasis.Conclusions. These findings strengthen the evidence that neighborhood structural conditions are associated with individual sexually transmitted infection (STI) acquisition. Research is needed to explore the mechanisms through which these conditions influence STI. In addition, STI-prevention programs that include structural interventions targeting neighborhood disadvantage are needed.Adolescents and young adults are at increased risk for sexually transmitted infections (STIs) because of a complex interplay of biological, behavioral, and developmental factors.¹ Nearly half of all STIs diagnosed in the United States annually are among adolescents and young adults^1,2 despite national priority goals aimed at reducing infection rates.³ Trichomoniasis, a common and easily curable STI,¹ is of increasing concern because the infection facilitates HIV acquisition and transmission through mucosal inflammation of the genital tract and alterations in the innate immune response. ^4-7 The infection is caused by the protozoa, Trichomonas vaginalis, and is typically transmitted via penis-to-vagina or vulva-to-vulva contact.¹ Infected persons are often asymptomatic or experience only mild symptoms,¹ which can hinder early detection and treatment and increase the risk of STIs and HIV.In the United States, the prevalence of trichomoniasis is difficult to ascertain because routine screening currently is not recommended nor is the reporting of positive results required.^1,4 According to urine assay data from the National Longitudinal Study of Adolescent Health (Add Health), the prevalence of trichomoniasis among the young adult population in 2001–2002 was approximately 2.3%.⁷ The study also found that women were at greater risk than were men (2.8% vs 1.7%) as were non-Hispanic Black (6.9%) and Latino (2.1%) youths compared with their non-Hispanic White peers (1.2%).⁷ In other studies of adult women, individual risk factors for trichomoniasis included poverty, lower education, douching, non-Hispanic Black race/ethnicity, and greater numbers of lifetime sexual partners.^8,9 Among clinic samples of adolescent women, research found trichomoniasis to be associated with older male sexual partners, casual sexual activity, marijuana use, and delinquency.¹⁰However, to date, no studies have examined the role of the broader structural context in shaping trichomoniasis risk, despite theory and previous STI research suggesting that the neighborhood environment may play a role. According to social disorganization theory,^11–14 key indicators of neighborhood structural disadvantage (i.e., racial/ethnic composition, concentrated poverty, and residential instability) influence health outcomes by weakening social ties, reducing access to institutional resources, and limiting exposure to positive role models, conventional social norms, and collective efficacy. Findings from previous research examining other STIs support the hypothesis that neighborhood contexts influence STI prevalence. For example, with respect to racial and ethnic composition, studies have found that gonorrhea rates were higher in cities and neighborhoods with greater proportions of Black residents.^15,16 Furthermore, in an analysis of Chicago neighborhoods, the incidence rates of gonorrhea and chlamydia were higher for neighborhoods in which more than 60% of the residents were Black compared with those in which more than 60% of residents were Hispanic, which suggests that segregated Hispanic ethnic enclaves may be protective of STI compared with segregated Black communities.¹⁷ Researchers hypothesize that the residential segregation of Black communities has contributed to the pervasive Black-White disparities in STI through discrimination processes, which in turn has led to greater concentration of poverty, lower male-to-female gender ratios due to the disproportionate incarceration and mortality of Black men, and closed, racially segregated sexual networks that facilitate the transmission of infection.^18–20In addition, the role of community poverty in shaping STI risk has been examined extensively and found to be positively associated with rates of chlamydia, gonorrhea, syphilis, and HIV in cross-sectional^{15,17,21–23} and longitudinal analyses.¹⁶ Other socioeconomic factors, such as unemployment^17,24 and lower educational attainment,^16,17 have also been linked to higher rates of chlamydia and gonorrhea. Research on the effects of residential instability on STI is limited, but the single study that examined these relationships found greater residential instability was associated with fewer self-reported STIs among a national sample of adolescents.²⁴ Depending on the context, perhaps residential instability could increase STI risk by disrupting social support ties and informal social control measures or reduce STI risk by dispersing closed sexual networks that facilitate infection transmission.Although the aforementioned studies have illustrated links between neighborhood social disorganization and a variety of STIs, limitations exist. First, the majority have been ecological studies, in which the outcomes were measured as community STI rates and no adjustment was made for potential confounding relationships with individual-level data.^{15–17,21–23} Consequently, inferences can be made only about the community, and individual variation in the outcome cannot be ascertained.²⁵ Second, although 1 study examined individual STI, the measure was based on self-report,²⁴ which potentially increases bias because of underreporting as well as unrecognized or undiagnosed infection. In addition, the study only focused on STI in general, which could limit our understanding of unique relationships with specific infectious organisms. Third, data sources of previous research tend to be at local or state levels,^{15–17,21–23} which limits external validity of the findings. Therefore, the purpose of our research was to examine relationships between neighborhood social disorganization and trichomoniasis among young adults in the United States. Our research builds on previous studies in 3 significant ways: (1) we examined multiple levels of analysis, which enabled us to simultaneously examine the independent relationships between individual and neighborhood variables and individual acquisition of trichomoniasis, (2) we examined a more refined measure of STI through the use of urine screening, and (3) we examined data from a large national data set—Add Health.     

African American women's lifetime upward economic mobility and preterm birth: the effect of fetal programming

Objectives. We investigated whether African American mothers’ upward economic mobility across the life course and having been of low birth weight are associated with the preterm birth of their children.Methods. We performed stratified and multilevel logistic regression analyses on an Illinois transgenerational data set of African American infants (born 1989–1991) and their mothers (n = 11 265; born 1956–1976) with appended US Census income information.Results. African American mothers with a lifelong residence in impoverished neighborhoods had a preterm birthrate of 18.7%. African American mothers with early life impoverishment who experienced low, modest, or high upward economic mobility by adulthood had lower preterm birthrates of 16.0% (rate ratio [RR] = 0.9; 95% confidence interval [CI] = 0.8, 0.9), 15.2% (RR = 0.8; 95% CI = 0.7, 0.9), and 12.4% (RR = 0.7; 95% CI = 0.6, 0.8), respectively. In multilevel logistic regression models of former low birth weight and non–low birth weight mothers aged 20 to 35 years, the adjusted odds ratio (95% confidence interval) of preterm birth for those who experienced high upward economic mobility (vs those with lifelong impoverishment) was 0.9 (0.5-1.6) and 0.7 (0.5-0.9), respectively.Conclusions. African American mother''s upward economic mobility from early life impoverishment is associated with a decreased risk of preterm birth. However, consistent with fetal programming, this phenomenon fails to occur among mothers born at low birth weight.African American women''s increased risk of preterm birth is a long-standing epidemiological enigma and a major public health problem.^1–3 Moreover, it contributes to the United States’ poor international ranking in preterm births.⁴ A life course conceptual model has been proposed to explain the adverse pregnancy outcome of African American women.^5–7 In this model, the high rate of preterm birth among African American (compared with non-Latino White) women reflects their higher prevalence of contextual risk factors and their paucity of protective contextual factors across the entire life course from conception until reproductive age.⁷Numerous studies show that neighborhood poverty is a risk factor for preterm birth in both races.^8–10 By contrast, a limited available literature shows that African American and White women''s exposure to neighborhood affluence during adulthood is a contextual phenomenon associated with a lower risk of preterm birth.^10,11 However, these studies employed cross-sectional designs in which ecological risk estimates were derived from women''s place of residence at or near the time of delivery. Given the disproportionately large percentage of African American (compared with White) women with early life residence in impoverished neighborhoods,¹² the impact of upward economic mobility across the life course on pregnancy outcome may be particularly important in helping us understand and eliminate the mechanisms underlying the racial disparity in preterm birth. Colen et al. provided preliminary evidence that upward socioeconomic mobility measured at the individual level was associated with lower rates of low birth weight (LBW; < 2500 g) among a sample of White women who were poor as children, but this trend did not occur among African Americans.¹³ A more recent population-based study found that infant LBW rates declined as the adulthood economic environment of African American women with early life exposure to neighborhood poverty improved.¹⁴ To our knowledge, no study has ascertained the impact of upward economic mobility from early life impoverishment to adulthood affluence on preterm birth and infant mortality.Fetal programming acts at the level of the DNA in a phenomenon called epigenetics. There has been a rapid outpouring of studies that describe what is programmed during fetal life with regard to the health status of that fetus as an adult.^15–17 Researchers have used LBW as the major marker for aberrant fetal programming. LBW is a well-documented risk factor for the leading chronic diseases of adulthood, including type II diabetes, coronary artery disease, and hypertension.^15–17 Fetal undernutrition is the leading explanation.¹⁶ An expanding literature shows that maternal LBW is also a risk factor for preterm birth in both races.^18–20 Thus, disadvantaged economic conditions may limit the growth of a woman''s fetuses and program her reproductive physiology to deliver preterm infants during adulthood. This effect may be related to altered feedback resistance as a consequence of altered expression of glucocorticoid receptors in the developing female fetal brain.^21–25 The extent to which aberrant female reproductive programming modifies the association of contextual factors across the life course and preterm birth is incompletely understood.We, therefore, undertook an analysis of Illinois vital records and US Census income data to determine the extent to which former LBW and non–LBW African American women''s upward economic mobility across the life course is associated with the preterm birth of their children. We hypothesized that African American women''s upward economic mobility from early life residence in impoverished neighborhoods to adulthood residence in affluent neighborhoods is a protective contextual phenomenon associated with a lower risk of preterm birth.     

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity).Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities.There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.Tobacco products and their marketing materials are ubiquitous in US retailers from pharmacies to corner stores.1 A similar presence is found across the globe, except in countries that ban point-of-sale (POS) tobacco marketing (e.g., Australia, Canada, Thailand2). In the United States, the POS has become the main communications channel for tobacco marketing3,4 and is reported as a source of exposure to tobacco marketing by more than 75% of US youths.5 Burgeoning evidence6,7 suggests that marketing at the POS is associated with youths’ brand preference,8 smoking initiation,9 impulse purchases,10,11 and compromised quit attempts.12,13The marketing of tobacco products is not uniform; it is clear from industry documents that the tobacco industry has calibrated its marketing to target specific demographic groups defined by race,14 ethnicity,15 income,16 mental health status,17 gender,18,19 and sexual orientation.20 Framed as an issue of social and environmental justice,14 research has documented historical racial, ethnic, and socioeconomic disparities in the presence of tobacco billboards,21–25 racial disparities in total tobacco marketing volume,24 and targeting of menthol cigarettes to communities with more Black residents.25,26 Targeted marketing of a consumer product that kills up to half27 of its users when used as directed exacerbates inequities in morbidity and mortality. Smoking is estimated to be responsible for close to half of the difference in mortality between men in the lowest and highest socioeconomic groups.28 However, evidence of marketing disparities is scattered across multiple disciplines and marketing outcomes, such as product availability, advertising quantity, presence of promotional discounts, and price. A synthesis of this literature would provide valuable information for intervention on tobacco marketing in the retail environment and inform etiological research on health disparities.To address this gap in the literature, we systematically reviewed observational studies that examined the presence and quantity of POS tobacco marketing to determine the extent to which marketing disparities exist by neighborhood demographic characteristic (i.e., socioeconomic disadvantage, race, ethnicity, and urbanicity).     

Association of Perceived Neighborhood Safety on Body Mass Index

Objectives. We sought to determine whether there is an association between perceived neighborhood safety and body mass index (BMI), accounting for endogeneity.Methods. A random sample of 2255 adults from the Los Angeles Family and Neighborhood Survey 2000–2001 was analyzed using instrumental variables. The main outcome was BMI using self-reported height and weight, and the main independent variable was residents’ report of their neighborhood safety.Results. In adjusted analyses, individuals who perceived their neighborhoods as unsafe had a BMI that was 2.81 kg/m² (95% confidence interval [CI] = 0.11, 5.52) higher than did those who perceived their neighborhoods as safe.Conclusions. Our results suggest that clinical and public health interventions aimed at reducing rates of obesity may be enhanced by strategies to modify the physical and social environment that incorporate residents’ perceptions of their communities.Obesity is a major public health problem^1–5 that contributes to poor quality of life; increased incidence of diabetes, cardiovascular disease, and other chronic conditions; and higher mortality rates.⁵ During the last decade, population-based strategies to reduce obesity have emphasized modification of physical and social environments, which may be particularly important in disadvantaged communities. Low neighborhood socioeconomic status (SES),⁶ a higher proportion of Black and Latino residents,^7–10 barriers in the built environment (e.g., fewer places to walk),^11,12 lack of access to supermarkets or fresh fruits and vegetables,^6,13,14 and a higher density of fast food restaurants¹⁵ are all characteristics of residential environments associated with obesity. Research also suggests that low levels of collective efficacy (a perception of mutual trust and willingness to help each other)¹⁶ are associated with adolescent obesity. However, the mechanisms through which neighborhood social, economic, and physical characteristics lead to weight gain and obesity are not well characterized.Perceived neighborhood safety is a mechanism through which neighborhood characteristics may influence obesity. Residence in a neighborhood perceived as unsafe may contribute to obesity in a number of ways, including increased secretion of stress hormones,^17–19 lower rates of walking or other outdoor physical activity,^20–28 and higher rates of stress-related eating.^29–32 Perceived safety may reflect the physical, social, and resource characteristics of neighborhoods. For example, residents may perceive a neighborhood to be unsafe if supermarkets and retailers that sell fresh fruits and vegetables are unwilling to locate in their neighborhoods, or if fast food restaurants and stores that sell low-cost, calorie-dense foods tend to locate in their neighborhoods.^33–35 Yet, the limited literature on relations between perceived safety and body weight is mixed. One study found that mothers with young children, residing in large cities, and perceiving their neighborhoods as unsafe were more likely to be obese,³⁶ and another study found no association between perceived safety and obesity.³⁷ Similarly, in the larger body of literature on neighborhood safety and physical activity, some studies found an association of perceived neighborhood safety with physical activity levels,^20–26 although other analyses showed no such relationship,^38–42 suggesting a more complex etiology.We hypothesized that 1 reason for the inconsistent findings in these previous analyses—all of which were cross-sectional—is endogeneity bias, that is, the possibility that the findings from these studies may have been influenced by either reverse causality^36,43 or unmeasured neighborhood or individual characteristics influencing both perceived neighborhood safety and obesity. For example, reverse causality may occur if larger individuals, believing nobody would attack them because of their size, feel safer, or if larger individuals, being less agile and less physically fit and believing they cannot protect themselves, feel less safe. To address the possibility of endogeneity from reverse causality or unmeasured neighborhood or individual characteristics, we studied the association between perceived neighborhood safety and obesity in a population-based, geographically sampled cohort of residents in Los Angeles County, California. We used 2-stage least squares regression, a special case of an instrumental variables analysis that is a method developed to produce statistically consistent estimates when the covariate of interest is potentially endogenous. To our knowledge, no studies to date have used instrumental variables analysis to assess the relationship between neighborhood safety and obesity.     

The Role of Socioeconomic Factors in Black–White Disparities in Preterm Birth

Objectives. We investigated the role of socioeconomic factors in Black–White disparities in preterm birth (PTB).Methods. We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables.Results. Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black–White disparities within the most socioeconomically disadvantaged subgroups; Black–White disparities were seen only within more advantaged subgroups.Conclusions. Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black–White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature—including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate—as potential contributors to PTB among Black and White women with different levels of social advantage.Higher rates of preterm birth (PTB) among Blacks than Whites have been documented in the United States since at least the early 20th century.1–3 This racial disparity is of great concern because PTB strongly predicts infant mortality4,5 and adverse health and neurodevelopmental outcomes in childhood,4,6,7 and has been linked with chronic disease, disability, and premature mortality in adulthood.8–10The underlying reasons for the racial disparity in PTB are not well understood.4 A range of socioeconomic factors—including income, wealth, and education at the individual, household, and area levels—vary across racial/ethnic groups11–16 and are biologically plausible underlying causes of PTB.4,17–20 Socioeconomic effects on health, including PTB, could operate independently of and in concert with the effects of stressful experiences related more directly to racial discrimination.4,16,21,22 Many studies have observed different PTB risks associated with socioeconomic or socioeconomically linked characteristics of the geographic areas where women reside,4,11,23–32 including area-level measures of poverty, unemployment,26 segregation,24,28 and crime rates.25 Various individual-, household-, and neighborhood-level socioeconomic factors could plausibly affect PTB through diverse causal pathways, including those involving poor nutrition or prepregnancy health status, adverse health-related behaviors, lack of medical care, social isolation, stress, and hazardous physical exposures in the home, neighborhood, workplace, or in transit.4 Biological pathways leading from stressful experiences to PTB through neuroendocrine processes have been described.33–36A systematic review17 of studies examining relationships between adverse birth outcomes and socioeconomic factors found that 93 of 106 studies reported a significant association, overall or within a subgroup, between a socioeconomic measure and a birth outcome; effects varied, however, across racial/ethnic groups and socioeconomic measures. Several birth outcome studies have examined interactions between variables reflecting racial/ethnic group and socioeconomic factors, with inconsistent results. Some studies have found minimal or no Black–White differences in PTB among highly disadvantaged women.37–39 Others have observed a significant racial disparity among socioeconomically disadvantaged women, but an even greater disparity among more socioeconomically advantaged women.24,40,41 Some other studies, however, have not reported differences in the racial disparity in PTB across socioeconomic subgroups.4 Although the biological mechanisms for low birth weight are thought to be distinct from those for PTB,4 several studies42–49 have observed relatively smaller—but not necessarily small—racial disparities in low birth weight or infant mortality within socioeconomically disadvantaged versus more advantaged subgroups.In some studies, the Black–White disparity in PTB has persisted after adjustment for socioeconomic and other known or suspected risk factors,31,50–52 leading some researchers to conclude that the Black–White disparity in PTB reflects underlying genetic differences.53–56 Others have challenged this, noting that the disparity may reflect significant unmeasured socioeconomic factors and other social experiences including those related to racial discrimination throughout life, not only during pregnancy.18,21,57–62 With few exceptions,30,31,39,63,64 however, most studies of the Black–White disparity in PTB have had limited socioeconomic information, and few have examined systematically how the disparity may vary at different socioeconomic levels.The goal of this study was to investigate the role of socioeconomic factors in the Black–White disparity in PTB by using a unique population-based data source on California births with more extensive information than generally available in previous PTB research, including multiple socioeconomic measures at the individual, household, and area levels and a wide range of covariables reflecting potential confounders suggested by the literature. The aim was to assess the combined contribution of multiple socioeconomic factors—representing different dimensions of social advantage and disadvantage—to the racial disparity in PTB, and to examine whether and how these socioeconomic factors might moderate the relationship between racial group and PTB.     

Joint Effects of Structural Racism and Income Inequality on Small-for-Gestational-Age Birth

Objectives. We examined potential synergistic effects of racial and socioeconomic inequality associated with small-for-gestational-age (SGA) birth.Methods. Electronic medical records from singleton births to White and Black women in 10 US states and the District of Columbia (n = 121 758) were linked to state-level indicators of structural racism, including the ratios of Blacks to Whites who were employed, were incarcerated, and had a bachelor’s or higher degree. We used state-level Gini coefficients to assess income inequality. Generalized estimating equations models were used to quantify the adjusted odds of SGA birth associated with each indicator and the joint effects of structural racism and income inequality.Results. Structural racism indicators were associated with higher odds of SGA birth, and similar effects were observed for both races. The joint effects of racial and income inequality were significantly associated with SGA birth only when levels of both were high; in areas with high inequality levels, adjusted odds ratios ranged from 1.81 to 2.11 for the 3 structural racism indicators.Conclusions. High levels of racial inequality and socioeconomic inequality appear to increase the risk of SGA birth, particularly when they co-occur.In the United States, Black women are more than 1.5 times as likely as White women to give birth to a small-for-gestational-age (SGA) infant, typically defined as an infant with a birth weight below the 10th percentile for a given gestational age; such births increase the risk of neonatal morbidity and long-term deficits in growth and development.1 This disparity has persisted for decades and is not fully explained by differences in health behaviors or access to prenatal care.2–4 Although individual socioeconomic status attenuates some of the increase in risk experienced by Black women, residual disparities remain.5Racial discrimination may be a distinct and critical source of chronic stress among women of color, both during pregnancy and across the life course.6 Disparities in perinatal outcomes, including SGA birth, are of particular interest to researchers concerned with the potential health effects of discrimination. A growing body of research has identified the harmful effects of racial discrimination on the health of Blacks in the United States.7 Evidence suggests that discrimination may be at least partially responsible for the large and persistent disparities in morbidity and mortality that exist between Whites and Americans of color.8 Much of this research has focused on individual experiences of discrimination, but a relatively recent paradigm shift has begun to identify such experiences as part of a larger system of policies and practices that reinforce racial inequity.9This system refers to the concept of structural racism, defined as the exclusion of racial minorities from resources and opportunities (e.g., wealth, housing, education), effectively creating a health disadvantage.10 The historical legacy of racial oppression experienced by Black Americans9,11 and persistent differences in access to resources have resulted in a system of strong links between race and social class at the population level. Inequalities in health therefore are not driven by race or class alone,12 and disentangling the health effects of both racial and socioeconomic disadvantage continues to present conceptual and methodological difficulties.13Previous work highlighting the detrimental effects of structural racism on pregnancy outcomes, including infant size and gestational age at delivery, has been largely limited to analyses of neighborhood or metropolitan area contexts such as segregation patterns,14–19 deprivation,20–23 and crime,24 which may stem from, for example, discriminatory mortgage lending, population differences in buying power, and federal housing policies.25 Furthermore, studies that have considered contextual socioeconomic characteristics have produced inconsistent results in terms of the degree to which these factors explain racial disparities in adverse birth outcomes between neighborhoods.15,19,21It remains unknown whether structural racism measured at the state level is associated with SGA birth. In a recent investigation of structural racism and myocardial infarction, Lukachko et al. developed a series of state-level indicators intended to represent the systematic exclusion of people of color from access to resources, opportunities, and social mobility.26 Using similar indicators, we investigated the potential synergistic effects of state-level structural racism and socioeconomic inequality on the risk of SGA birth among White and Black women in a large US obstetrical cohort study. We aimed to describe the degree of structural racism across the study states, determine whether the effects of structural racism differed according to maternal race and across levels of income inequality, and quantify the risk of SGA birth associated with high levels of both racial and socioeconomic inequality.     

Racial,Ethnic, and Socioeconomic Differences in the Incidence of Obesity Related to Childbirth

Objectives. We investigated the relationship between childbirth and 5-year incidence of obesity.Methods. We performed a prospective analysis of data on 2923 nonobese, nonpregnant women aged 14 to 22 years from the 1979 National Longitudinal Survey of Youth Cohort, which was followed from 1980 to 1990. We used multivariable logistic regression analyses to determine the adjusted relative risk of obesity for mothers 5 years after childbirth compared with women who did not have children.Results. The 5-year incidence of obesity was 11.3 per 100 parous women, compared with 4.5 per 100 nulliparous women (relative risk [RR] = 3.5; 95% confidence interval [CI] = 2.4, 4.9; P < .001). The 5-year incidence of obesity was 8.6 for primiparous women (RR = 2.8; 95% CI = 1.5, 5.0) and 12.2 for multiparous women (RR = 3.8; 95% CI = 2.6, 5.6). Among parous women, White women had the lowest obesity incidence (9.1 per 100 vs 15.1 per 100 for African Americans and 12.5 per 100 for Hispanics).Conclusions. Parous women have a higher incidence of obesity than do nulliparous women, and minority women have a higher incidence of parity-related obesity than do White women. Thus, efforts to reduce obesity should target postpartum women and minority women who give birth.Women in the United States are disproportionately overweight, particularly minority and socioeconomically disadvantaged women.^1,2 Approximately two thirds of adult women are overweight, and of this group, one third are obese.¹ Among racial/ethnic groups, African American and Hispanic women have the highest prevalences of obesity, at 50% and 40%, respectively.¹ Women who are socioeconomically disadvantaged have higher obesity rates than do women of higher socioeconomic standing.³ In addition, emerging evidence links perinatal factors such as parity (number of births) to obesity in later life,^4–9 although researchers investigating the relationship between parity and major weight gain or obesity have found mixed results.^7,10–17Several studies have reported that multiparous women (those who have had 2 or more live births) were more likely to be overweight than were nulliparous women (those who have never had a live birth).^10–13,15 Another study found that primiparous women (those who have had at least 1 live birth) were more likely to be overweight and to have major long-term weight gain than were multiparous and nulliparous women.¹⁷ Other studies have found little or no relationship between parity and weight gain or obesity.^7,12,14,16 The inconsistencies in these findings may stem from differences in definitions of the main outcomes, the use of cross-sectional study designs versus prospective designs, or the exclusion of prevalent cases of obesity at baseline. The majority of these studies focused on the outcomes of mean body mass index (BMI), mean weight gain, weight change, major weight gain, or prevalence of obesity, but not on the incidence of parity-related obesity. Additionally, these studies did not establish that births occurred before the outcome measured.^10,12,13,16 Nor have these studies investigated whether racial/ethnic or socioeconomic differences exist in the incidence of parity-related obesity. Thus, we used prospective data to determine the 5-year incidence of parity-related obesity among our sample and to investigate whether this incidence varied by race/ethnicity or socioeconomic status.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis

Objectives. We assessed whether markers of acculturation (birthplace and number of US generations) and socioeconomic status (SES) are associated with markers of subclinical cardiovascular disease—carotid artery plaque, internal carotid intima-media thickness, and albuminuria—in 4 racial/ethnic groups.Methods. With data from the Multi-Ethnic Study of Atherosclerosis (n = 6716 participants aged 45–84 years) and race-specific binomial regression models, we computed prevalence ratios adjusted for demographics and traditional cardiovascular risk factors.Results. The adjusted US- to foreign-born prevalence ratio for carotid plaque was 1.20 (99% confidence interval [CI] = 0.97, 1.39) among Whites, 1.91 (99% CI = 0.94, 2.94) among Chinese, 1.62 (99% CI = 1.28, 2.06) among Blacks, and 1.23 (99% CI = 1.15, 1.31) among Hispanics. Greater carotid plaque prevalence was found among Whites, Blacks, and Hispanics with a greater number of generations with US residence (P < .001) and among Whites with less education and among Blacks with lower incomes. Similar associations were observed with intima-media thickness. There was also evidence of an inverse association between albuminuria and SES among Whites and Hispanics.Conclusions. Greater US acculturation and lower SES were associated with a higher prevalence of carotid plaque and greater intima-media thickness but not with albuminuria. Maintenance of healthful habits among recent immigrants should be encouraged.Beginning with the Ni-Hon-San study,^1,2 which was initiated in the 1960s, research has associated increased acculturation to Western lifestyles with more-adverse cardiovascular disease (CVD) risk factor profiles and with increased CVD morbidity and mortality. Specifically, greater Western acculturation has frequently been linked to increased body mass index (BMI; weight in kilograms divided by height in meters squared),^3–5 waist circumference and abdominal obesity,^6,7 hypertension,^7–9 type II diabetes,^10,11 and CVD morbidity and mortality.^1,12,13 However, little research has explored associations between acculturation and subclinical CVD.^14,15Abundant research also exists that links low socioeconomic status (SES) to increased levels of CVD risk factors, morbidity, and mortality.^14,16–18 In general, SES has been found to be inversely related to subclinical measures of CVD, including coronary artery calcification (CAC),^14,19–22 carotid artery plaque, and intima-media thickness^20,23–26 and albuminuria.²⁷ Relations with peripheral artery disease have been inconsistent.^28–30 The extent to which these associations vary by race/ethnicity has been examined infrequently. There is, however, some evidence that the relation between SES and disease may differ across racial/ethnic groups.^14,31,32 Specifically, in the Multi-Ethnic Study of Atherosclerosis (MESA) there was a higher prevalence of CAC among Whites with low education than among those with more education, whereas the reverse was true for Hispanics.¹⁴We investigated whether acculturation and SES were associated with other measures of subclinical disease, specifically with carotid plaque and albuminuria. The relation of acculturation and SES to CAC has been described in MESA.¹⁴ Although CAC, carotid plaque, and albuminuria are all subclinical measures of CVD and are related to adverse clinical outcomes, these measures represent different aspects of the disease process and have relatively weak intercorrelations.³³ Thus, they may be differentially related to our exposures of interest.The investigation of these patterns is important from a public health perspective and may yield clues regarding the etiology of atherosclerosis. On the basis of previous work,¹⁴ we hypothesized that increased Western acculturation, as assessed by place of birth, migration history, and duration of US residence, is associated with increased carotid plaque, intima-media thickness, and albuminuria. Additionally, we expected there to be an interaction between race/ethnicity and SES with respect to their associations with subclinical CVD. Specifically, we expected Whites and Blacks at lower SES to have more-adverse subclinical CVD profiles than those at higher SES, whereas for Hispanics and Chinese, we expected the reverse to be true.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

Neighborhood Characteristics and Change in Depressive Symptoms Among Older Residents of New York City

Objectives. We investigated the relationship between the depressive symptoms of older adults over time and the characteristics of the neighborhoods in which they live.Methods. We surveyed a random sample of 1325 New York City residents aged 50 years or older in 2005 and conducted 808 follow-up interviews in 2007. We assessed the compositional characteristics of the respondents'' neighborhoods at a census-tract level and determined the relationships between these characteristics and changes in respondents'' depressive symptoms.Results. In multivariable models that adjusted for individual-level covariates including income, a range of neighborhood characteristics predicted worsening depressive symptoms. Factor analysis suggested that these characteristics operated in 3 clusters: neighborhood socioeconomic influences, residential stability, and racial/ethnic composition, with positive neighborhood socioeconomic influences being significantly protective against worsening symptoms. Life stressors, personality trait neuroticism, African American race, and daily baseline contact with social networks were also associated with worsening symptoms.Conclusions. An older adult''s neighborhood of residence is an important determinant of his or her mental health. Those making efforts to improve mental health among the elderly need to consider the role of residential context in improving or impairing mental health.Depression is an important cause of morbidity in the general community.¹ The prevalence of depression is high among elderly persons, and longitudinal studies have found modest increases in depressive symptoms with age.^2–4 The incidence of depression peaks in early adult life, but there appears to be a secondary peak in incidence among people in their 50s, suggesting that the transition to older age may present specific risks for depression.⁵ Depression is associated with significant disability among older adults and may place their functional independence at risk.⁶ At least 1 longitudinal study has also suggested that older African Americans may be at increased risk of symptoms of depression compared with older White adults.⁷Although a number of individual-level factors are known to increase the risk of depression,^8–10 it has long been thought that the physical and social environments in which people live may also influence their mental health.^11–13 The environment may play a particularly important role in the mental health of older adults, who, compared with younger adults, are more likely to spend time in their neighborhood of residence, more likely to suffer from disabilities that may be exacerbated by their environments,¹⁴ and are more vulnerable to threats to their safety.^15–17A number of theories have been proposed to explain this association between neighborhood characteristics and depression. Researchers have drawn on systemic theory to propose that neighborhoods characterized by higher levels of poverty and residential instability have lower levels of social cohesion and lower levels of control over deviant social networks.^18,19 The concomitant lack of social order may contribute to low levels of trust, which would impede collaborative efforts to control crime and reduce neighborhood disorder.²⁰ High levels of crime may generate higher levels of fear and stress, as could the deteriorating building conditions and high levels of physical disorder associated with disadvantaged neighborhoods.^20,21 In contexts of social isolation and limited social organization, residents may not benefit from the social networks necessary to buffer them from the stressors they face on a daily basis.²²These theories about the influence of the neighborhood context on collective and individual sources of stress agree with the “differential vulnerability” hypothesis and with social stress theory, both of which posit that environments can influence health by increasing the likelihood of personal stress events such as unemployment or traumatic events, or by providing resources to cope with such stressors.^23–26 Studies using multilevel analytic methods that can account for both individual-level and neighborhood-level effects suggest that neighborhood-level characteristics such as affluence, disadvantage, inequality, and residential stability have a significant impact on physical health, even after accounting for individual-level factors.^27–30 However, research into their possible influence on mental health has been more limited.Cross-sectional studies using multilevel approaches have suggested that symptoms of depression are more prevalent in residents of disadvantaged neighborhoods^31–33 and that this association may be stronger in neighborhoods having less residential turnover^34,35 or higher population density.³⁶ Similar associations have been observed among older adults, for whom living in a neighborhood that is poor or has few elderly people has been associated with higher levels of depressive symptoms, after accounting for individual vulnerabilities.³⁷ The presence of stress-buffering support systems has been associated with lower levels of depression in cross-sectional research, whereas low levels of social support in neighborhoods with high social isolation were related to higher depression levels.^38,39 However, other research has failed to replicate these findings.⁴⁰ Furthermore, the cross-sectional nature of this research means that even positive studies cannot exclude the possibility that the observed relationships simply reflect a tendency for depressed individuals to become disadvantaged or to live in disadvantaged neighborhoods.Longitudinal research can better explore the causal mechanisms behind these relationships, but there have been few prospective studies in this field. A study of individuals who were screened for an HIV prevention intervention found that perceptions of neighborhood characteristics predicted change in depressive symptoms 9 months later.⁴¹ The Alameda County Study found that living in a high-poverty area was associated with worse health status and more symptoms of depression; however, this association was lost when all individual-level covariates were included in multivariable analysis.⁴² In previous research conducted by members of our own team, we identified a significant association between incident depression and neighborhoods classified as low socioeconomic status, even after adjusting for individual income, adverse life events, and educational status.⁴³ This kind of prospective research, although suggestive, has often been weakened by reliance on perceived neighborhood characteristics, limitations of the measures used, or absence of information on possible confounders.To overcome these limitations, we examined the relationship between characteristics of the neighborhood of residence of older adults and symptoms of depression using longitudinal data from the New York City Neighborhood and Mental Health in the Elderly Study (NYCNAMES). We hypothesized that neighborhood socioeconomic status may either exacerbate or ameliorate the stressors confronting participants, thereby influencing levels of depression symptoms over the study period, even after accounting for key individual-level factors. We used information from the 2000 US Census to characterize neighborhoods, and we aggregated these characteristics into dimensions that might shed light on the mechanisms underlying observed relationships.