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Reliable and stable environmental audit instruments are needed to successfully identify the physical and social attributes that may influence physical activity. This study described the reliability and stability of the PIN3 environmental audit instrument in both urban and rural neighborhoods. Four randomly sampled road segments in and around a one-quarter mile buffer of participants' residences from the Pregnancy, Infection, and Nutrition (PIN3) study were rated twice, approximately 2 weeks apart. One year later, 253 of the year 1 sampled roads were re-audited. The instrument included 43 measures that resulted in 73 item scores for calculation of percent overall agreement, kappa statistics, and log-linear models. For same-day reliability, 81% of items had moderate to outstanding kappa statistics (kappas ≥ 0.4). Two-week reliability was slightly lower, with 77% of items having moderate to outstanding agreement using kappa statistics. One-year stability had 68% of items showing moderate to outstanding agreement using kappa statistics. The reliability of the audit measures was largely consistent when comparing urban to rural locations, with only 8% of items exhibiting significant differences (α < 0.05) by urbanicity. The PIN3 instrument is a reliable and stable audit tool for studies assessing neighborhood attributes in urban and rural environments.

Purpose: The inter-relationships between objective (census based) and subjective (resident reported) measures of the residential environment is understudied in African American (AA) populations., Methods: Using data from the Life Influences on Fetal Environments Study (2009-2011; n = 1387) of AA women, we quantified the area-level variation in subjective reports of residential healthy food availability, walkability, safety, and disorder that can be accounted for with an objective neighborhood disadvantage index (NDI). Two-level generalized linear models estimated associations between objective and subjective measures of the residential environment, accounting for individual-level covariates., Results: In unconditional models, intraclass correlation coefficients for block-group variance in subjective reports ranged from 11% (healthy food availability) to 30% (safety). Models accounting for the NDI (vs. both NDI and individual-level covariates) accounted for more variance in healthy food availability (23% vs. 8%) and social disorder (40% vs. 38%). The NDI and individual-level variables accounted for 39% and 51% of the area-level variation in walkability and safety, respectively. Associations between subjective and objective measures of the residential environment were significant and in the expected direction., Conclusions: Future studies on neighborhood effects on health, especially among AAs, should include a wide range of residential environment measures, including subjective, objective, and spatial contextual variables., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Racial residential segregation has been associated with preterm birth. Few studies have examined mediating pathways, in part because, with binary outcomes, indirect effects estimated from multiplicative models generally lack causal interpretation. We develop a method to estimate additive-scale natural direct and indirect effects from logistic regression. We then evaluate whether segregation operates through poor-quality built environment to affect preterm birth., Methods: To estimate natural direct and indirect effects, we derive risk differences from logistic regression coefficients. Birth records (2000-2008) for Durham, North Carolina, were linked to neighborhood-level measures of racial isolation and a composite construct of poor-quality built environment. We decomposed the total effect of racial isolation on preterm birth into direct and indirect effects., Results: The adjusted total effect of an interquartile increase in racial isolation on preterm birth was an extra 27 preterm events per 1000 births (risk difference = 0.027 [95% confidence interval = 0.007 to 0.047]). With poor-quality built environment held at the level it would take under isolation at the 25th percentile, the direct effect of an interquartile increase in isolation was 0.022 (-0.001 to 0.042). Poor-quality built environment accounted for 35% (11% to 65%) of the total effect., Conclusion: Our methodology facilitates the estimation of additive-scale natural effects with binary outcomes. In this study, the total effect of racial segregation on preterm birth was partially mediated by poor-quality built environment.

The determinants that underlie a healthy or unhealthy pregnancy are complex and not well understood. We assess the relationship between the built environment and maternal psychosocial status using directly observed residential neighborhood characteristics (housing damage, property disorder, tenure status, vacancy, security measures, violent crime, and nuisances) and a wide range of psychosocial attributes (interpersonal support evaluation list, self-efficacy, John Henryism active coping, negative partner support, Perceived Stress Scale, perceived racism, Center for Epidemiologic Studies-Depression) on a pregnant cohort of women living in the urban core of Durham, NC, USA. We found some associations between built environment characteristic and psychosocial health varied by exposure categorization approach, while others (residence in environments with more rental property is associated with higher reported active coping and negative partner support) were consistent across exposure categorizations. This study outlines specific neighborhood characteristics that are modifiable risk markers and therefore important targets for increased research and public health intervention.

The purpose of this research was to assess the consistency of associations between neighborhood characteristics and pregnancy-related behaviors and outcomes across four nested neighborhood boundaries using race-stratified fixed-slope random-intercept multilevel logistic models. High incivilities was associated with increased smoking, inadequate weight gain and pregnancy-induced hypertension (PIH), while walkability was associated with decreased smoking and PIH for white women across all neighborhood definitions. For African American women, high incivilities was associated with increased smoking and inadequate gestational weight gain, while more walkable neighborhoods appeared protective against smoking and inadequate weight gain in all but the smallest neighborhoods. Associations with neighborhood attributes were similar in effect size across geographies, but less precise as neighborhoods became smaller., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The built environment, a key component of environmental health, may be an important contributor to health disparities, particularly for reproductive health outcomes., Objective: In this study we investigated the relationship between seven indices of residential built environment quality and adverse reproductive outcomes for the City of Durham, North Carolina (USA)., Methods: We surveyed approximately 17,000 residential tax parcels in central Durham, assessing > 50 individual variables on each. These data, collected using direct observation, were combined with tax assessor, public safety, and U.S. Census data to construct seven indices representing important domains of the residential built environment: housing damage, property disorder, security measures, tenure (owner or renter occupied), vacancy, crime count, and nuisance count. Fixed-slope random-intercept multilevel models estimated the association between the residential built environment and five adverse birth outcomes. Models were adjusted for maternal characteristics and clustered at the primary adjacency community unit, defined as the index block, plus all adjacent blocks that share any portion of a line segment (block boundary) or vertex., Results: Five built environment indices (housing damage, property disorder, tenure, vacancy, and nuisance count) were associated with each of the five outcomes in the unadjusted context: preterm birth, small for gestational age (SGA), low birth weight (LBW), continuous birth weight, and birth weight percentile for gestational age (BWPGA; sex-specific birth weight distributions for infants delivered at each gestational age using National Center for Health Statistics referent births for 2000-2004). However, some estimates were attenuated after adjustment. In models adjusted for individual-level covariates, housing damage remained statistically significantly associated with SGA, birth weight, and BWPGA., Conclusion: This work suggests a real and meaningful relationship between the quality of the residential built environment and birth outcomes, which we argue are a good measure of general community health.

Previous studies of black-white disparities in perinatal outcomes have generally not controlled for both observed and unobserved neighborhood inequalities with models that compare only black and white women living in the same neighborhoods. Using 1999-2001 birth certificate data from 2 counties in North Carolina, the authors employed a hybrid fixed-effects approach to assess the total contribution of neighborhood factors to both absolute and relative racial disparities in low birth weight, preterm birth (PTB), and smallness for gestational age at term. Neighborhood factors made a notable contribution to racial disparities for PTB only, accounting for an additional 15% reduction in crude disparities beyond individual sociodemographic characteristics, which accounted for approximately 40% of racial disparities. The neighborhood contribution was greater for moderate PTB (32-36 weeks' gestation) than for very PTB (<32 weeks' gestation). A neighborhood deprivation index accounted for a smaller percentage of PTB disparities than the hybrid fixed-effects estimates, which suggests that measured socioeconomic deprivation does not account for all health-relevant neighborhood inequalities. Contemporaneous individual-level sociodemographic and neighborhood factors together explained one- to two-thirds of perinatal disparities. To fully explain racial disparities in perinatal outcomes, evaluation of other differential exposures (e.g., racism or wealth) and neighborhood factors across the life course may be necessary.

Confounding associated with social stratification or other selection processes has been called structural confounding. In the presence of structural confounding, certain covariate strata will contain only subjects who could never be exposed, a violation of the positivity or experimental treatment effect assumption. Thus, structural confounding can prohibit the exchangeability necessary for meaningful causal contrasts across levels of exposure. The authors explored the presence and magnitude of structural confounding by estimating the independent effects of neighborhood deprivation and neighborhood racial composition (segregation) on rates of preterm birth in Wake and Durham counties, North Carolina (1999-2001). Tabular analyses and random-intercept fixed-slope multilevel logistic models portrayed different structural realities in these counties. The multilevel modeling results suggested some nonsignificant effect of residence in tracts with high levels of socioeconomic deprivation or racial residential segregation on adjusted odds of preterm birth for white and black women living in these counties, and the confidence limit ratios indicated fairly consistent levels of precision around the estimates. The results of the tabular analysis, however, suggested that many of these regression modeling findings were off-support and based on no actual data. The implications for statistical and public health inference, in the presence of no data, are considered.

Background: Leaders are struggling to care for the estimated 143,000,000 orphans and millions more abandoned children worldwide. Global policy makers are advocating that institution-living orphans and abandoned children (OAC) be moved as quickly as possible to a residential family setting and that institutional care be used as a last resort. This analysis tests the hypothesis that institutional care for OAC aged 6-12 is associated with worse health and wellbeing than community residential care using conservative two-tail tests., Methodology: The Positive Outcomes for Orphans (POFO) study employed two-stage random sampling survey methodology in 6 sites across 5 countries to identify 1,357 institution-living and 1,480 community-living OAC ages 6-12, 658 of whom were double-orphans or abandoned by both biological parents. Survey analytic techniques were used to compare cognitive functioning, emotion, behavior, physical health, and growth. Linear mixed-effects models were used to estimate the proportion of variability in child outcomes attributable to the study site, care setting, and child levels and institutional versus community care settings. Conservative analyses limited the community living children to double-orphans or abandoned children., Principal Findings: Health, emotional and cognitive functioning, and physical growth were no worse for institution-living than community-living OAC, and generally better than for community-living OAC cared for by persons other than a biological parent. Differences between study sites explained 2-23% of the total variability in child outcomes, while differences between care settings within sites explained 8-21%. Differences among children within care settings explained 64-87%. After adjusting for sites, age, and gender, institution vs. community-living explained only 0.3-7% of the variability in child outcomes., Conclusion: This study does not support the hypothesis that institutional care is systematically associated with poorer wellbeing than community care for OAC aged 6-12 in those countries facing the greatest OAC burden. Much greater variability among children within care settings was observed than among care settings type. Methodologically rigorous studies must be conducted in those countries facing the new OAC epidemic in order to understand which characteristics of care promote child wellbeing. Such characteristics may transcend the structural definitions of institutions or family homes.

Epidemiologic research suggests that racial segregation is associated with poor health among blacks in the United States (US). We used geocoded birth records and US census data to investigate whether neighborhood-level percent black is associated with preterm birth (PTB) for black and white women in two counties in the southern US, whether area-level deprivation modifies this association, and whether the association is influenced by the choice of geographic unit used to approximate a neighborhood. A 20%-point increase in tract-level percent black was found to be associated with increased PTB odds in white (OR=1.09, 95% CI: 1.01, 1.18) and black (OR=1.05, 95% CI: 0.99, 1.11) women. These small associations were similar to those observed in other US regions. Effects were robust to choice of neighborhood proxy and were not modified by area-level deprivation.

Residential context has received increased attention as a possible contributing factor to race/ethnic and socio-economic disparities in birth outcomes in the United States. Utilising vital statistics birth record data, this study examined the association between neighbourhood deprivation and the risk of a term small-for-gestational-age (SGA) birth among non-Hispanic whites and non-Hispanic blacks in eight geographical areas. An SGA birth was defined as a newborn weighing <10th percentile of the sex- and parity-specific birthweight distribution for a given gestational week. Multi-level random intercept logistic regression models were employed and statistical tests were performed to examine whether the association between neighbourhood deprivation and SGA varied by race/ethnicity and study site. The risk of term SGA was higher among non-Hispanic blacks (range 10.8-17.5%) than non-Hispanic whites (range 5.1-9.2%) in all areas and it was higher in cities than in suburban locations. In all areas, non-Hispanic blacks lived in more deprived neighbourhoods than non-Hispanic whites. However, the adjusted associations between neighbourhood deprivation and term SGA did not vary significantly by race/ethnicity or study site. The summary fully adjusted pooled odds ratios, indicating the effect of one standard deviation increase in the deprivation score, were 1.15 [95% CI 1.08, 1.22] for non-Hispanic whites and 1.09 [95% CI 1.05, 1.14] for non-Hispanic blacks. Thus, neighbourhood deprivation was weakly associated with term SGA among both non-Hispanic whites and non-Hispanic blacks.

Disparities in preterm birth by race and ethnic group have been demonstrated in the United States. Recent research has focused on the impact of neighborhood context on racial disparities in pregnancy outcomes. The authors utilized vital-record birth certificate data and US Census data from eight geographic areas in four states (Maryland, Michigan, North Carolina, and Pennsylvania) to examine the relation between neighborhood deprivation and preterm birth among non-Hispanic White and Black women. The years covered by the data varied by site and ranged from 1995 to 2001. Results were adjusted for maternal age and education, and specific attention was paid to racial and geographic differences in the relation between neighborhood deprivation and preterm birth. Preterm birth rates were higher for non-Hispanic Blacks (10.42-15.97%) than for non-Hispanic Whites (5.77-9.13%), and neighborhood deprivation index values varied substantially across the eight areas. A significant association was found between neighborhood deprivation and risk of preterm birth; for the first quintile of the deprivation index versus the fifth, the adjusted summary odds ratio was 1.57 (95% confidence interval: 1.41, 1.74) for non-Hispanic Whites and 1.15 (95% confidence interval: 1.08, 1.23) for non-Hispanic Blacks. In this study, deprivation at the neighborhood level was significantly associated with increased risk of preterm birth among both non-Hispanic White women and non-Hispanic Black women.

Healthy diet, physical activity, smoking, and adequate weight gain are all associated with maternal health and fetal growth during pregnancy. Neighborhood characteristics have been associated with poor maternal and child health outcomes, yet conceptualization of potential mechanisms are still needed. Unique information captured by neighborhood inventories, mostly conducted in northern US and Canadian urban areas, has been shown to reveal important aspects of the community environment that are not captured by the demographic quantities in census data. This study used data from the Pregnancy, Nutrition, and Infection (PIN) prospective cohort study to estimate the influences of individual-level and neighborhood-level characteristics on health behaviors and adequacy of weight gain during pregnancy. Women who participated in the PIN study and who resided in Raleigh, North Carolina and its surrounding suburbs were included (n = 703). Results from a neighborhood data collection inventory identified three social constructs, physical incivilities, territoriality, and social spaces, which were hypothesized to influence maternal health behaviors. The physical incivility scale was associated with decreased odds (adjusted OR = 0.74, 95%CI = 0.57, 0.98) in participating in vigorous leisure activity before pregnancy after controlling for several individual confounders, and a crude association for decreased odds of excessive weight gain (OR = 0.79, 95%CI = 0.64, 0.98). The social spaces scale was associated with decreased odds for inadequate (adjusted OR = 0.74, 95%CI = 0.56, 0.98) and excessive (adjusted OR = 0.69, 95%CI = 0.54, 0.98) gestational weight gain. The social spaces scale was also associated with decreased odds of living greater than 3 miles from a supermarket (adjusted OR = 0.03, 95%CI = 0.00, 0.27). Territoriality was not associated with any pregnancy-related health behavior. None of the neighborhood constructs were associated with smoking or diet quality. Physical incivilities and social spaces neighborhood characteristics may be important to measure to improve our understanding of the potential mechanisms through which neighborhood environments influence health.

The "neighborhood effects" literature, as currently constructed in epidemiology, would benefit from critical attention to the following four issues: 1) use of appropriate measurement tools and methods for neighborhood environments; 2) theoretical or conceptual guidance as to the aspects of residential environments most salient to human health (both within and across health endpoints); 3) the scale on which investigators measure neighborhood environments to best correspond to meaningful neighborhood boundaries and relevant neighborhood exposures; and 4) those selection and structural features that confound investigators' capacity to draw causal inferences from neighborhood environments to human health. In this issue of the Journal, Mujahid et al. (Am J Epidemiol 2007;165:858-867) report on the psychometric and ecometric results of their neighborhood scale testing. By providing a more rigorous approach to testing of neighborhood-attribute measurement tools, they make an important contribution to the literature. Also noteworthy is their explicit use of a conceptual model, which may facilitate the development of more meaningful area-level measures. Unfortunately, while Mujahid et al. had the capacity to consider spatially relevant measures, based on prior research and their conceptual model, they relied exclusively on aggregated census units. Hopefully, the scale issue will be addressed more thoroughly in future work. Clearly, Mujahid et al. have made progress in addressing how, and to a lesser extent what, to measure when researchers estimate neighborhood effects. But equally clearly, important work remains to be done.

Census data are widely used for assessing neighborhood socioeconomic context. Research using census data has been inconsistent in variable choice and usually limited to single geographic areas. This paper seeks to a) outline a process for developing a neighborhood deprivation index using principal components analysis and b) demonstrate an example of its utility for identifying contextual variables that are associated with perinatal health outcomes across diverse geographic areas. Year 2000 U.S. Census and vital records birth data (1998-2001) were merged at the census tract level for 19 cities (located in three states) and five suburban counties (located in three states), which were used to create eight study areas within four states. Census variables representing five socio-demographic domains previously associated with health outcomes, including income/poverty, education, employment, housing, and occupation, were empirically summarized using principal components analysis. The resulting first principal component, hereafter referred to as neighborhood deprivation, accounted for 51 to 73% of the total variability across eight study areas. Component loadings were consistent both within and across study areas (0.2-0.4), suggesting that each variable contributes approximately equally to "deprivation" across diverse geographies. The deprivation index was associated with the unadjusted prevalence of preterm birth and low birth weight for white non-Hispanic and to a lesser extent for black non-Hispanic women across the eight sites. The high correlations between census variables, the inherent multidimensionality of constructs like neighborhood deprivation, and the observed associations with birth outcomes suggest the utility of using a deprivation, index for research into neighborhood effects on adverse birth outcomes.

Purpose: The racial disparity in preterm birth (PTB) is a persistent feature of perinatal epidemiology. Its consistency is not only an outcome of reproductive interest but may function as a persistent inequality to which women are exposed over time. Herein we sought to analyze exposure to area-level PTB disparity and its association with individual-level PTB risk. Methods: Using geocoded birth records (1999–2001) and year 2000 census data for Wake County, North Carolina, we created a tract-level PTB disparity variable for each woman in our study area, comprising all births in her tract excluding her birth. Multilevel random intercept models for exposure to neighborhood PTB disparity and odds of PTB were fit. Results: Exposure to area-level PTB disparity was associated with increased odds of PTB for all women. After adjustment for maternal and neighborhood covariates, odds of delivering preterm increased by 25%, 26%, and 36% for the second, third, and fourth quartiles of exposure to PTB disparity (odds ratio [OR]=1.25, 95% confidence interval [CI]: 1.00–1.57; OR=1.26, 95% CI: 1.01–1.58; and OR=1.36, 95% CI: 1.06–1.75, respectively). Conclusions: Exposure to persistent inequality, in the form of PTB disparity, appears associated with individual-level PTB risk. Knowing where PTB disparity is greatest has implications for PTB prevention policy efforts to buffer adverse conditions. [Copyright &y& Elsevier]

Purpose: Significant racial disparity in preterm birth (PTB; birth at <37 weeks'' gestation) exists, poorly explained by Individual-level factors. This research explores whether neighborhood crime contributes to the racial disparity in PTB. Methods: Geocoded Wake County, NC, birth records and crime-report data for 1999 to 2001 were merged with US Census data (2000). Race-stratified logistic and multilevel logistic models produced odds ratios (ORs) and 95% confidence intervals (CIs) for block-group violent, theft, property, and vice crime rates and singleton PTB. Results: A total of 13,960 women resided in a 114-block-group crime area. Non-Hispanic black women were more likely than non-Hispanic white women to deliver preterm (12.8% versus 6.7%), live in economically deprived block groups (42.2% versus 19.3% in the highest deprivation quartile), and experience more crime (32.0% versus 3.8% in the highest violent-crime-rate quartile). Quartiles of violent, theft, property, and vice crimes were associated with PTB in unadjusted models. Living in very high violent-crime-rate block-group quartiles was suggestive of increased odds of PTB for white and black non-Hispanic women (OR = 1.5; 95% CI, 0.9–2.6; and OR = 1.4; 95% CI, 1.0–2.1, respectively) in adjusted models. Other crime effects were attenuated after adjustment. Conclusions: Differential neighborhood exposures may contribute to racial disparity in PTB. [Copyright &y& Elsevier]

Weathering—the cumulative burden of adverse psychosocial and economic circumstances on the bodies of minority women—has been repeatedly described in epidemiologic studies. The most common application has been the documentation of rapidly increasing risks of adverse birth outcomes as African-American women age. Previous work has been based largely on cross-sectional data that aggregate women across a variety of socioeconomic circumstances. When more specific information about women's life-course socioeconomic status is taken into account, however, heterogeneity in the weathering experience of African-American women becomes more readily apparent. Adverse birth outcome risk trajectories with advancing age for African-American women who reside in wealthier neighborhoods look much more similar to those of white women. The accompanying article by Love et al. (Am J Epidemiol. 2010;172(2):127–134) provides a more nuanced investigation of the social conditions that contribute to the weathering of African-American women and points to the critical role played by social and economic conditions over the life course in producing adverse birth outcome disparities. [ABSTRACT FROM PUBLISHER]