Neighborhood-Level Interventions to Improve Childhood Opportunity and Lift Children Out of Poverty

doi:10.1016/j.acap.2016.01.013

Academic Pediatrics

Volume 16, Issue 3, Supplement, April 2016, Pages S128-S135

https://doi.org/10.1016/j.acap.2016.01.013 Get rights and content

Abstract

Population health is associated with the socioeconomic characteristics of neighborhoods. There is considerable scientific and policy interest in community-level interventions to alleviate child poverty. Intergenerational poverty is associated with inequitable access to opportunities. Improving opportunity structures within neighborhoods may contribute to improved child health and development. Neighborhood-level efforts to alleviate poverty for all children require alignment of cross-sector efforts, community engagement, and multifactorial approaches that consider the role of people as well as place. We highlight several accessible tools and strategies that health practitioners can engage to improve regional and local systems that influence child opportunity. The Child Opportunity Index is a population-level surveillance tool to describe community-level resources and inequities in US metropolitan areas. The case studies reviewed outline strategies for creating higher opportunity neighborhoods for pediatricians interested in working across sectors to address the impact of neighborhood opportunity on child health and well-being.

Section snippets

Defining Place for Intervention

While maximizing opportunities is important in shaping the well-being of families and children,⁴ the primary strategies to address this issue emerge from what can feel like dueling ideologies. As Turner has noted, there is a false dichotomy between mobility assistance to move low-income children to higher opportunity neighborhoods and “place-based” neighborhood revitalization to improve opportunity structures within impoverished neighborhoods.¹⁸ Turner argues that to address neighborhood-level

Defining Place by Both People and Geography

When considering how to intervene within a neighborhood, it is essential to define where to do the intervention by people as much as geography. While concentrated poverty influences health through a neighborhood-level effect, the influence of neighborhoods can also be felt through networks of social support or social cohesion. One example of this is neighborhood collective efficacy, which is defined as the linkage of mutual trust and the willingness to intervene for the common good.²² Examples

Opportunity Mapping

In addition to defining place by the people who live there, it is also essential to target interventions geographically. One tool for this is the Child Opportunity Index (COI).²⁷ Developed by Diversity Data Kids (http://www.diversitydatakids.org/) at Brandeis University and the Kirwan Institute on Race and Ethnicity at Ohio State University, this tool integrates multiple indicators of child-relevant neighborhood opportunity in a composite index by neighborhood in each of the 100 largest

Importance of Community Engagement and Leadership Development

Community engagement is a central component of community-level interventions. Thoughtful engagement of community members at every stage of planning, implementation, and evaluation can create greater equity and potential for success. While an anchor institution such as a hospital, university, or local nonprofit may be the driving agent of change for the neighborhood-level intervention, the process must not be a solely top-down approach but rather must engage in bottom-up methods.

Case Studies in Neighborhood-Level Interventions

The following case studies illustrate different community-engaged, multisector, multifactorial partnerships to improve opportunity and collective efficacy in neighborhoods. These are not meant to replace the pioneering work of Geoffrey Canada and the Harlem Children's Zone or to be an exhaustive list. Other excellent examples exist from across the country, such as University California at San Francisco, led by Anda Kuo. The Build Healthy Places Network, led by Doug Jutte, provides many

Discussion

Addressing neighborhood inequities through mobility to higher opportunity and neighborhood revitalization both remain important strategies to improve child health. Place-based neighborhood level interventions that focus on building equity of opportunity and collective efficacy are crucial to lifting children out of poverty. This approach acknowledges regional differences in housing and labor markets, driven by racial/ethnic and socioeconomic inequities, lead to disparate amounts of

Conclusion

Socioeconomic characteristics of neighborhoods are a well-established pathway through which poverty contributes to child health outcomes. Understanding the contribution of collective attributes of neighborhood environments to child health offers a deeper opportunity to influence population health and well-being by transforming environments where children live, learn, and play. As opposed to disease-specific interventions that target individual health behaviors, community-level prevention aims

References (29)

R. Juster et al.
Allostatic load biomarkers of chronic stress and impact on health and cognition
Neurosci Biobehav Rev
(2010)
G. Howard et al.
Race, socioeconomic status, and cause-specific mortality
Ann Epidemiol
(2000)
J. Siegrist et al.
Health inequalities and the psychosocial environment
Soc Sci Med
(2004)
E. Teig et al.
Collective efficacy in Denver, Colorado: strengthening neighborhoods and health through community gardens
Health Place
(2009)
M. Marmot
The influence of income on health: views of an epidemiologist
Health Aff
(2002)
K. Conroy et al.
Poverty grown up: how childhood socioeconomic status impacts adult health
J Dev Behav Pediatr
(2010)
Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health
(2008)
T. Leventhal et al.
The neighborhoods they live in: the effects of neighborhood residence on child and adolescent outcomes
Psychol Bull
(2000)
F. Earls et al.
The social ecology of child health and well-being
Annu Rev Public Health
(2001)
J. Shonkoff et al.
The lifelong effects of early childhood adversity and toxic stress
Pediatrics
(2012)

V.J. Edwards et al.

Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the Adverse Childhood Experiences Study

Am J Psychiatry

(2003)

N. Slopen et al.

Childhood adversity, adult neighborhood context, and cumulative biological risk for chronic diseases in adulthood

Psychosom Med

(2014)

T. Seeman et al.

Socioeconomic differentials in peripheral biology: cumulative allostatic load

Ann N Y Acad Sci

(2010)

H.C. Bucher et al.

Socioeconomic indicators and mortality from coronary heart disease and cancer: a 22-year follow-up of middle-aged men

Am J Public Health

(1995)

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Association of Neighborhood Environment with the Outcomes of Childhood Glaucoma
2023, Ophthalmology Glaucoma
To determine the association between different neighborhood environment factors and the outcomes of childhood glaucoma.
A retrospective cohort.
Childhood glaucoma patients ≤ 18 years of age at the time of diagnosis.
A retrospective chart review of childhood glaucoma patients who presented to Boston Children’s Hospital between 2014 and 2019. Data collected included etiology, intraocular pressure (IOP), management, and visual outcomes. Child Opportunity Index (COI) was used as a metric of neighborhood quality.
The association of visual acuity (VA) and IOP with COI scores using linear mixed-effect models, adjusting for individual demographics.
A total of 221 eyes (149 patients) were included. Of these, 54.36% were male and 56.4% were non-Hispanic Whites. The median age at the time of presentation was 5 months for primary glaucoma and 5 years for secondary glaucoma. The median age at the last follow-up was 6 and 13 years for primary and secondary glaucoma, respectively. A chi-square test revealed that the COI, health and environment, social and economic, and education indexes between primary and secondary glaucoma patients were comparable. For primary glaucoma, the overall COI and a higher education index were associated with a lower final IOP (P < 0.05), and higher education index was associated with a lower number of glaucoma medications at the last follow-up (P < 0.05). For secondary glaucoma, higher overall COI, health and environment, social and economic, and education indices were associated with better final VA (lower logarithms of the minimum angle of resolution VA) (P < 0.001).
Neighborhood environment quality is a potentially important variable for predicting outcomes in childhood glaucoma. Lower COI scores were associated with worse outcomes.
Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
The effects of the historical practice of residential redlining in the United States on recent temporal trends of air pollution near New York City schools
2022, Environment International
Citation Excerpt :
Also, in our study, schools in historically redlined neighborhoods had inequity of opportunities and limited resources such as access to green space and healthy food options for children. Multi-faceted, community-level interventions that aim to change places and social environments can improve child health, development, and well-being (Sandel et al. 2016). We acknowledge several limitations to our study.
In the 1930's the United States (US) sponsored Home Owners’ Loan Corporation (HOLC) created maps that determined risk for mortgage lending based on the racial and ethnic composition of neighborhoods leading to disinvestment in “redlined” or highest risk neighborhoods. This historical practice has perpetuated racial and economic segregation, and health disparities, that persist today. Interventions near schools where children spend large portions of the day, could impact large groups of children but schools are an often-overlooked environment for exposure. Despite a declining trend of ambient pollution in New York City (NYC) between 1998 and 2012, little is known about differences in air quality improvement near schools by historical redlining neighborhood status. Our objective was to examine if recent temporal trends of air pollution near NYC public schools differed in historically redlined neighborhoods.
We examined annual average street-level concentrations of combustion-related air pollutants (black carbon (BC), particulate matter (PM_2.5), nitrogen dioxide (NO₂), and nitric oxide (NO)), within a 250-m radius around schools using NYC Community Air Survey land-use regression models (n = 1,462). Year of monitoring, historical redlining (binary), and summer ozone were included in multivariable linear regression using generalized estimating equation models. Average annual percent change (APC) in pollutant concentration was calculated. Models were further stratified by historical redlining and a multiplicative interaction term (year of monitoring × historical redlining) was used to assess effect modification.
Overall, there was a decreasing trend of BC (APC = -4.40%), PM_2.5 (-3.92%), NO₂ (-2.76%), and NO (-6.20%) during the 10-year period. A smaller reduction of BC, PM_2.5 and NO was observed in redlined neighborhoods (n = 722), compared to others (n = 740): BC (APC: −4.11% vs −4.69%; P_interaction < 0.01), PM_2.5 (-3.82% vs −4.11%; P_interaction < 0.01), and NO (-5.73% vs −6.67%; P_interaction < 0.01). Temporal trends of NO₂ did not differ by historical redlining (P_interaction = 0.60).
Despite significant reductions in annual average pollution concentrations across NYC, schools in historically redlined neighborhoods, compared to others, experienced smaller decrease in pollution, highlighting a potential ongoing ramification of the discriminatory practice.
Hospital-Level Neighborhood Opportunity and Rehospitalization for Common Diagnoses at US Children's Hospitals
2022, Academic Pediatrics
Citation Excerpt :
Knowledge of a child's neighborhood COI may prompt clinicians to understand the family's access to outpatient resources and seek appropriately targeted referrals to community-based interventions such as asthma home management programs.34 Children's hospitals might use COI and utilization data to identify neighborhoods in which to invest in community or school-based partnerships with the greatest potential to improve health.34,35 In a broader sense, as anchor institutions, hospitals and healthcare systems carry a responsibility to not only treat patients within their walls but to identify and eliminate health disparities in the broader communities they serve.
Neighborhood conditions influence child health outcomes, but data examining association between local factors and hospital utilization are lacking. We determined if hospitals’ mix of patients by neighborhood opportunity correlates with rehospitalization for common diagnoses at US children's hospitals.
We analyzed all discharges in 2018 for children ≤18 years at 47 children's hospitals for 14 common diagnoses. The exposure was hospital-level mean neighborhood opportunity – measured by Child Opportunity Index (COI) – for each diagnosis. The outcome was same-cause rehospitalization within 365 days. We measured association via Pearson correlation coefficient. For diagnoses with significant associations, we also examined shorter rehospitalization time windows and compared unadjusted and COI-adjusted rehospitalization rates.
There were 256,871 discharges included. Hospital-level COI ranged from 17th to 70th percentile nationally. Hospitals serving lower COI neighborhoods had more frequent rehospitalization for asthma (ρ −0.34 [95% confidence interval −0.57, −0.06]) and diabetes (ρ −0.33 [−0.56, −0.04]), but fewer primary mental health rehospitalizations (ρ 0.47 [0.21, 0.67]). There was no association for 11 other diagnoses. Secondary timepoint analysis revealed increasing correlation over time, with differences by diagnosis. Adjustment for hospital-level COI resulted in 26%, 32%, and 45% of hospitals changing >1 decile in rehospitalization rank order for diabetes, asthma, and mental health diagnoses, respectively.
Children's hospitals vary widely in their mix of neighborhoods served. Asthma, diabetes, and mental health rehospitalization rates correlate with COI, suggesting that neighborhood factors may influence outcome disparities for these conditions. Hospital outcomes may be affected by neighborhood opportunity, which has implications for benchmarking.
Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index
2022, Academic Pediatrics
Citation Excerpt :
Screening for social risk factors (such as food insecurity), in the primary care or ED settings, incentives for patients in publicly insured programs at asthma education programs and use of controller medications for patients with asthma or hydroxyurea use for patients with sickle cell disease, and connecting families to community-based resources represent other actionable steps to address the environmental factors that might drive these findings. Others have advocated for stakeholder engagement and community mobilization through neighborhood-level initiatives.32 We demonstrate that the influence of COI differs based on patient acuity (as defined by CPT codes), with a higher proportion of lower acuity encounters among children from lower COI groups.
To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI).
We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics.
There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models.
Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.
Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States
2021, Journal of Pediatrics
Citation Excerpt :
To address excess healthcare utilization among children, the findings of this study speak to the potential value in particular of addressing negative attributes of built neighborhood environments. Such conditions have indeed become a target of burgeoning efforts around the country to remediate substandard housing, vacant lots, illegal dumping, and vandalism.59,60 One citywide randomized trial demonstrated multiple benefits of greening of blighted vacant land, including improved mental health among local residents and reductions in violent crime.50,61-64
To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US.
This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics.
In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81).
Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.
Housing Is Health: A Renewed Call for Federal Housing Investments in Affordable Housing for Families With Children
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: The first 2 authors contributed equally to this article, and both should be considered first author.

: Conflict of Interest: The authors declare that they have no conflict of interest.

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Child Poverty Interventions in the USNeighborhood-Level Interventions to Improve Childhood Opportunity and Lift Children Out of Poverty

Abstract

Section snippets

Defining Place for Intervention

Defining Place by Both People and Geography

Opportunity Mapping

Importance of Community Engagement and Leadership Development

Case Studies in Neighborhood-Level Interventions

Discussion

Conclusion

Neurosci Biobehav Rev

Ann Epidemiol

Soc Sci Med

Health Place

The influence of income on health: views of an epidemiologist

Health Aff

Poverty grown up: how childhood socioeconomic status impacts adult health

J Dev Behav Pediatr

Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health

The neighborhoods they live in: the effects of neighborhood residence on child and adolescent outcomes

Psychol Bull

The social ecology of child health and well-being

Annu Rev Public Health

The lifelong effects of early childhood adversity and toxic stress

Pediatrics