Faculty Bibliography

Despite higher chronic disease prevalence, minoritized populations live in highly walkable neighborhoods in US cities more frequently than non-minoritized populations. We investigated whether city-level racial residential segregation (RRS) was associated with city-level walkability, stratified by population density, possibly explaining this counterintuitive association. RRS for Black-White and Latino-White segregation in large US cities was calculated using the Index of Dissimilarity (ID), and walkability was measured using WalkScore. Median walkability increased across increasing quartiles of population density, as expected. Higher ID was associated with higher walkability; associations varied in strength across strata of population density. RRS undergirds the observed association between walkability and minoritized populations, especially in higher population density cities.

OBJECTIVES:This study evaluated whether a range of demographic, social and geographic factors had an influence on glycaemic control longitudinally after an initial diagnosis of diabetes. DESIGN, SETTING AND PARTICIPANTS:We used the US Veterans Administration Diabetes Risk national cohort to track glycaemic control among patients 20-79-year old with a new diagnosis of type 2 diabetes. PRIMARY OUTCOME AND METHODS:We modelled associations between glycaemic control at follow-up clinical assessments and geographic factors including neighbourhood race/ethnicity, socioeconomic, land use and food environment measures. We also adjusted for individual demographics, comorbidities, haemoglobin A1c (HbA1c) at diagnosis and duration of follow-up. These factors were analysed within strata of community type: high-density urban, low-density urban, suburban/small town and rural areas. RESULTS:We analysed 246 079 Veterans who developed a new type 2 diabetes diagnosis in 2008-2018 and had at least 2 years of follow-up data available. Across all community types, we found that lower baseline HbA1c and female sex were strongly associated with a higher likelihood of within-range HbA1c at follow-up. Surprisingly, patients who were older or had more documented comorbidities were more likely to have within-range follow-up HbA1c results. While there was variation by community type, none of the geographic measures analysed consistently demonstrated significant associations with glycaemic control across all community types.

Vaccination is an indispensable tool to reduce negative outcomes due to COVID-19. Although COVID-19 disproportionately affected lower income and Black and Hispanic communities, these groups have had lower population-level uptake of vaccines. Using detailed cross-sectional data, we examined racial and ethnic group differences in New York City schoolchildren becoming fully vaccinated (two doses) within 6 months of vaccine eligibility. We matched school enrollment data to vaccination data in the Citywide Immunization Registry, a census of all vaccinations delivered in New York City. We used ordinary least squares regression models to predict fully vaccinated status, with key predictors of race and ethnicity using a variety of different control variables, including residential neighborhood or school fixed effects. We also stratified by borough and by age. The sample included all New York City public school students enrolled during the 2021-2022 school year. Asian students were most likely to be vaccinated and Black and White students least likely. Controlling for student characteristics, particularly residential neighborhood or school attended, diminished some of the race and ethnicity differences. Key differences were also present by borough, both overall and by racial and ethnic groups. In sum, racial and ethnic disparities in children's COVID-19 vaccination were present. Vaccination rates varied by the geographic unit of borough; controlling for neighborhood characteristics diminished some disparities by race and ethnicity. Neighborhood demographics and resources, and the attributes, culture and preferences of those who live there may affect vaccination decisions and could be targets of future efforts to increase vaccination rates.

IMPORTANCE:Despite recent growth in online redemption of Supplemental Nutrition Assistance Program (SNAP) benefits, no previous work has tested the impact of economic and behavioral economic strategies on food purchasing behaviors in an online grocery retail setting among adults with low income. OBJECTIVE:To examine the extent to which financial incentives and default shopping cart options influence fruit and vegetable purchases. DESIGN, SETTING, AND PARTICIPANTS:This randomized clinical trial used an experimental online grocery store for adults who currently or have ever received SNAP benefits. From October 7 to December 2, 2021, participants were instructed to shop for a week's worth of groceries for their household, with a budget tailored to household size; no payment was taken. INTERVENTIONS:Random assignment to 1 of 4 conditions: no intervention, 50% discount on eligible fruits and vegetables, prefilled shopping carts with tailored fruit and vegetable items (ie, default options), or a combination of the discount and default options. MAIN OUTCOMES AND MEASURES:The primary outcome was the percentage of nondiscounted dollars spent on eligible fruit and vegetables per basket. RESULTS:Of 2744 participants, mean (SD) age was 46.7 (16.0) years, and 1447 (52.7%) identified as women. A total of 1842 participants (67.1%) reported currently receiving SNAP benefits and 1492 (54.4%) reported shopping online for groceries in the previous 12 months. Participants spent a mean (SD) 20.5% (23.5%) of total dollars on eligible fruits and vegetables. Compared with no intervention, those in the discount condition spent 4.7% (98.3% CI, 1.7%-7.7%) of more total dollars on eligible fruits and vegetables; those in the default condition, 7.8% (98.3% CI, 4.8%-10.7%) more; and those in the combination condition, 13.0% (98.3% CI, 10.0%-16.0%) more (P < .001 for all). There was no difference between the discount and the default conditions (P = .06), but the effect in the combination condition was significantly larger than both discount and default conditions (P < .001). Default shopping cart items were purchased by 679 participants (93.4%) in the default condition and 655 (95.5%) in the combination condition, whereas 297 (45.8%) in the control and 361 (52.9%) in the discount conditions purchased those items (P < .001). No variation was observed by age, sex, or race and ethnicity, and results were similar when those who reported never shopping online for groceries were excluded. CONCLUSIONS AND RELEVANCE:In this randomized clinical trial, financial incentives for fruits and vegetables and default options, especially in combination, led to meaningful increases in online fruit and vegetable purchases among adults with low income. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04766034.

BACKGROUND:While emerging studies suggest that the COVID-19 pandemic caused disruptions in routine healthcare utilization, the full impact of the pandemic on healthcare utilization among diverse group of patients with type 2 diabetes is unclear. The purpose of this study is to examine trends in healthcare utilization, including in-person and telehealth visits, among U.S. veterans with type 2 diabetes before, during and after the onset of the COVID-19 pandemic, by demographics, pre-pandemic glycemic control, and geographic region. METHODS:We longitudinally examined healthcare utilization in a large national cohort of veterans with new diabetes diagnoses between January 1, 2008 and December 31, 2018. The analytic sample was 733,006 veterans with recently-diagnosed diabetes, at least 1 encounter with veterans administration between March 2018-2020, and followed through March 2021. Monthly rates of glycohemoglobin (HbA1c) measurements, in-person and telehealth outpatient visits, and prescription fills for diabetes and hypertension medications were compared before and after March 2020 using interrupted time-series design. Log-linear regression model was used for statistical analysis. Secular trends were modeled with penalized cubic splines. RESULTS:In the initial 3 months after the pandemic onset, we observed large reductions in monthly rates of HbA1c measurements, from 130 (95%CI,110-140) to 50 (95%CI,30-80) per 1000 veterans, and in-person outpatient visits, from 1830 (95%CI,1640-2040) to 810 (95%CI,710-930) per 1000 veterans. However, monthly rates of telehealth visits doubled between March 2020-2021 from 330 (95%CI,310-350) to 770 (95%CI,720-820) per 1000 veterans. This pattern of increases in telehealth utilization varied by community type, with lowest increase in rural areas, and by race/ethnicity, with highest increase among non-hispanic Black veterans. Combined in-person and telehealth outpatient visits rebounded to pre-pandemic levels after 3 months. Despite notable changes in HbA1c measurements and visits during that initial window, we observed no changes in prescription fills rates. CONCLUSIONS:Healthcare utilization among veterans with diabetes was substantially disrupted at the onset of the pandemic, but rebounded after 3 months. There was disparity in uptake of telehealth visits by geography and race/ethnicity.

Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke (SHS) exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory infections (LRIs), and upper respiratory infections (URIs) in the early post-policy period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to policy) to children living in lots with other subsidized housing (unexposed to policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015 and December 31, 2019 (policy introduction was July 30, 2018). We also examined effect modification by baseline age group (0-2, 3-6, 7-15). In NYC, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early post-policy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient URI claims (IRR=1.05, 95% CI=1.01, 1.08), a result most pronounced among children ages 3-6. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.

INTRODUCTION/BACKGROUND:In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein 'Section 8'). METHODS:We invited participants from non-smoking households (NYCHA n=157, Section 8 n=118) to enroll into a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bi-sulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n=91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. RESULTS:After three years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section 8, [difference-in-difference (DID) = -1.92 µg/m 3 (95% CI -2.98, -0.87), p=0.001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m 3 (95% CI -2.40, 0.18), p=0.089]. In households, there was no differential change in nicotine concentration (p=0.093) or in PM2.5 levels (p=0.385). CONCLUSIONS:Nicotine concentration reductions in NYCHA common areas over three years may be attributable to the SFH policy, reflecting its gradual implementation over this time. IMPLICATIONS/CONCLUSIONS:Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.

The view of owning a home as integral to the "American dream" is enshrined in numerous policies designed to promote homeownership. Whether or not these policies are worth their cost is unclear and depends, in part, on the extent to which owner-occupied housing (OOH) confers socially important benefits. Yet identifying the effects of OOH is complicated, not only due to standard concerns about selection, but also because OOH tends to be located in neighborhoods with better amenities (including schools) and is often synonymous with living in a single-family home. In this paper we use rich, longitudinal student-level data to examine whether students in OOH have better academic and health outcomes than those in renter occupied housing (ROH). We address concerns about selection using student fixed effects and a rich set of individual, building, and neighborhood controls. We find that that there is notable variation in both the characteristics and size of OOH and the types of students who live in OOH in NYC. While raw differences show that students who live in OOH have better outcomes-they are less likely to be chronically absent, obese, or overweight and have higher standardized test scores-much of this disparity is explained by differences in the students who select into OOH. In models where we account for selection into OOH and building type with rich controls and student fixed effects, we find small positive effects of moving into OOH on attendance and math scores with no consistent evidence of any impacts of OOH on BMI or obesity, suggesting that policies that promote homeownership might be oversold.

While advocates argue that gentrification changes the neighborhood food environment critical to children's diet and health, we have little evidence documenting such changes or the consequences for their health outcomes. Using rich longitudinal, individual-level data on nearly 115,000 New York City children, including egocentric measures of their food environment and BMI, we examine the link between neighborhood demographic change ("gentrification"), children's access to restaurants and supermarkets, and their weight outcomes. We find that children in rapidly gentrifying neighborhoods see increased access to fast food and wait-service restaurants and reduced access to corner stores and supermarkets compared to those in non-gentrifying areas. Boys and girls have higher BMI following gentrification, but only boys are more likely to be obese or overweight. We find public housing moderates the relationship between gentrification and weight, as children living in public housing are less likely to be obese or overweight.