Background Racial discrimination may increase the risk of low birthweight (LBW), but has not been studied among Roma, the largest minority population in Europe. Moreover, few studies test both institutional and interpersonal forms of racial discrimination on health. Our objective was to examine associations between institutional and interpersonal racial discrimination with LBW, and to test potential mediation by smoking during pregnancy. In 2012-2013, Romani women interviewers surveyed 410 Romani women in Serbia and Macedonia. We measured institutional discrimination (neighborhood segregation, legal status of housing and neighborhood socioeconomic status), interpersonal discrimination [Everyday Discrimination Scale (EDS)], birthweight and smoking by self-report or interviewer report. We estimated relative risks for discrimination on LBW and separately on smoking during pregnancy using log-binomial regression, adjusting for age, parity, years at residence and wealth. The indirect effect of high EDS via smoking on LBW was estimated using inverse odds weighting mediation. Living in a low SES neighborhood showed a 2-fold risk of LBW [adjusted risk ratio (aRR) = 2.4, 95% CI = 1.2, 5.0]; aRRs for segregation and illegal housing were weaker (aRR = 1.8, 95% CI = 0.7, 4.3; aRR = 1.3, 95% CI = 0.6, 2.6, respectively). Institutional measures were not associated with smoking. High EDS was associated with LBW (aRR = 2.4, 95% CI = 1.1, 5.2) and smoking during pregnancy (aRR = 1.4, 95% CI = 1.1, 1.8); the indirect effect of EDS on LBW via smoking was not significant. Interpersonal discrimination and living in a low SES neighborhood were associated with LBW among Roma. Interventions to improve Romani health may benefit from a human rights approach.

PURPOSE Test whether neighborhood mobility effects on adolescent risky behaviors varies at different developmental ages and gender. METHODS The Moving to Opportunity (MTO) study randomly assigned volunteer families (1994-1997) to receive a Section 8 voucher to move to lower poverty neighborhoods versus a public housing control group. We tested three-way treatment, gender, and age-at-randomization interactions using intent-to-treat linear regression predicting a risky behavior index (RBI; measured in 2002, N = 2,829), defined as the fraction of 10 behaviors the youth reported (six measuring risky substance use [RSU], four measuring risky sexual behavior), and the RSU and risky sexual behavior subscales. RESULTS The treatment main effect on RBI was nonsignificant for girls (B = -.01, 95% confidence interval -.024 to .014) and harmful for boys (B = .03, 95% confidence interval .009 to .059; treatment-gender interaction p = .01). The treatment, gender, and age interaction was significant for RBI (p = .02) and RSU (p ≤ .001). Treatment boys 10 years or older at randomization were more likely (p < .05) than controls to exhibit RBI and RSU, whereas there was no effect of treatment for boys <10 years. There were no treatment control differences by age for girls' RBI, but girls 9+ years were less likely than girls ≤8 years to exhibit RSU (p < .05). CONCLUSIONS Moving families of boys aged 10 years or older with rental vouchers may have adverse consequences on risky behaviors but may be beneficial for girls' substance use. Developmental windows are different by gender for the effects of improving neighborhood contexts on adolescent risky behavior.

BACKGROUND Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher poststroke mortality, and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke. METHODS AND RESULTS Health and Retirement Study participants aged ≥50 years without stroke at baseline (n=15 560) were followed ≤12 years for incident stroke (1715 events over 159 286 person-years) and mortality (5325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black, or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus people without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (hazard ratio, 0.75 for neighborhoods in highest 25th percentile versus below, 95% confidence interval, 0.62-0.91) more strongly than for stroke-free adults (hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within 3 months after stroke, when associations were often stronger than among stroke-free individuals. CONCLUSIONS Neighborhood characteristics predict mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional poststroke care.

We used the Moving to Opportunity (MTO) housing experiment to inform how housing choice vouchers and housing mobility policies can assist families living in high-poverty areas to make opportunity moves to higher quality neighborhoods, across a wide range of neighborhood attributes. We compared the neighborhood attainment of the three randomly-assigned MTO treatment groups (Low Poverty voucher, Section 8 voucher, Control group) at 1997 and 2002 locations (4-7 years after baseline), by using survey reports, and by linking residential histories to numerous different administrative and population-based datasets. Compared to controls, families in Low-Poverty and Section 8 groups experienced substantial improvements in neighborhood conditions across diverse measures, including economic conditions, social systems (e.g., collective efficacy), physical features of the environment (e.g., tree cover) and health outcomes. The Low-poverty voucher group moreover achieved better neighborhood attainment compared to Section 8. Treatment effects were largest for New York and Los Angeles. We discuss the implications of our findings for expanding affordable housing policy.

Child marriage (before age 18) is a risk factor for intimate partner violence (IPV) against women. Worldwide, Bangladesh has the highest prevalence of IPV and very early child marriage (before age 15). How the community prevalence of very early child marriage influences a woman's risk of IPV is unknown. Using panel data (2013-2014) from 3,355 women first married 4-12 years prior in 77 Bangladeshi villages, we tested the protective effect of a woman's later first marriage (at age 18 or older), the adverse effect of a higher village prevalence of very early child marriage, and whether any protective effect of a woman's later first marriage was diminished or reversed in villages where very early child marriage was more prevalent. Almost one-half (44.5 %) of women reported incident physical IPV, and 78.9 % had married before age 18. The village-level incidence of physical IPV ranged from 11.4 % to 75.0 %; the mean age at first marriage ranged from 14.8 to 18.0 years. The mean village-level prevalence of very early child marriage ranged from 3.9 % to 51.9 %. In main-effects models, marrying at 18 or later protected against physical IPV, and more prevalent very early child marriage before age 15 was a risk factor. The interaction of individual later marriage and the village prevalence of very early child marriage was positive; thus, the likely protective effect of marrying later was negated in villages where very early child marriage was prevalent. Collectively reducing very early child marriage may be needed to protect women from IPV.

INTRODUCTION Higher adult socioeconomic position (SEP) is associated with better birth outcomes. However, few studies incorporate life-course or intergenerational SEP, which may inform etiology and targeted prevention efforts. This study tested whether life-course social mobility from childhood was associated with lower risk of adverse birth outcomes. METHODS Data were from the Life-course Influences of Fetal Environments (LIFE) retrospective cohort study among black women, 2009-2011, in metropolitan Detroit, MI. This study (analyzed in 2014-2016) examined whether social mobility was associated with two primary birth outcomes: small for gestational age (SGA) and preterm birth (PTB). Childhood and adulthood SEP were measured by survey in adulthood, for two constructs, measured ordinally: educational attainment and perceived financial sufficiency (subjective income/wealth). Social mobility was calculated as the difference of adulthood minus childhood SEP. RESULTS In covariate-adjusted Poisson regression models, 1-SD improved educational social mobility from childhood to adulthood was protective for SGA (adjusted risk ratio=0.76; 95% CI=0.64, 0.91); this association remained after adjusting for financial mobility. Upward financial social mobility from early childhood was marginally protective for SGA (adjusted risk ratio=0.85; 95% CI=0.72, 1.02), but became nonsignificant after controlling educational mobility. There were no overall associations of social mobility with PTB or low birth weight, although sensitivity analyses identified that improved financial mobility was associated with 16% marginally lower risk of spontaneous PTB and 28% marginally lower risk of low birth weight among upwardly mobile/stable women only. CONCLUSIONS Improved life-course social mobility is associated with reduced risk for SGA and spontaneous PTB among black women.

OBJECTIVES To assess the mental health effects on adolescents of low-income families residing in high-poverty public housing who received housing vouchers to assist relocation. METHODS We defined treatment effects to compare 2829 adolescents aged 12 to 19 years in families offered housing vouchers versus those living in public housing in the Moving to Opportunity experiment (1994-1997; Boston, MA; Baltimore, MD; Chicago, IL; Los Angeles, CA; New York, NY). We employed model-based recursive partitioning to identify subgroups with heterogeneous treatment effects on psychological distress and behavior problems measured in 2002. We tested 35 potential baseline treatment modifiers. RESULTS For psychological distress, Chicago participants experienced null treatment effects. Outside Chicago, boys experienced detrimental effects, whereas girls experienced beneficial effects. Behavior problems effects were null for adolescents who were aged 10 years or younger at baseline. For adolescents who were older than 10 years at baseline, violent crime victimization, unmarried parents, and unsafe neighborhoods increased adverse treatment effects. Adolescents who were older than 10 years at baseline without learning problems or violent crime victimization, and whose parents moved for better schools, experienced beneficial effects. CONCLUSIONS Health effects of housing vouchers varied across subgroups. Supplemental services may be necessary for vulnerable subgroups for whom housing vouchers alone may not be beneficial.

The assumption that exposures as measured in observational settings have clear and specific definitions underpins epidemiologic research and allows us to use observational data to predict outcomes in interventions. This leap between exposures as measured and exposures as intervened upon is typically supported by the consistency assumption. The consistency assumption has received extensive attention in risk factor epidemiology but relatively little emphasis in social epidemiology. However, violations of the consistency assumption may be especially important to consider when understanding how social and economic exposures influence health. Efforts to clarify the definitions of our exposures, thus bolstering the consistency assumption, will help guide interventions to improve population health and reduce health disparities. This article focuses on the consistency assumption as considered within social epidemiology. We explain how this assumption is articulated in the causal inference literature and give examples of how it might be violated for three common exposure in social epidemiology research: income, education and neighborhood characteristics. We conclude that there is good reason to worry about consistency assumption violations in much of social epidemiology research. Theoretically motivated explorations of mechanisms along with empirical comparisons of research findings under alternative operationalizations of exposure can help identify consistency violations. We recommend that future social epidemiology studies be more explicit to name and discuss the consistency assumption when describing the exposure of interest, including reconciling disparate results in the literature.

PURPOSE This study sought to examine whether perceived interpersonal racism in the form of racial micro aggressions was associated with preterm birth (PTB) and whether the presence of depressive symptoms and perceived stress modified the association. METHODS Data stem from a cohort of 1410 black women residing in Metropolitan Detroit, Michigan, enrolled into the Life-course Influences on Fetal Environments (LIFE) study. The Daily Life Experiences of Racism and Bother (DLE-B) scale measured the frequency and perceived stressfulness of racial micro aggressions experienced during the past year. Severe past-week depressive symptomatology was measured by the Centers for Epidemiologic Studies-Depression scale (CES-D) dichotomized at ≥ 23. Restricted cubic splines were used to model nonlinearity between perceived racism and PTB. We used the Perceived Stress Scale to assess general stress perceptions. RESULTS Stratified spline regression analysis demonstrated that among those with severe depressive symptoms, perceived racism was not associated with PTB. However, perceived racism was significantly associated with PTB among women with mild to moderate (CES-D score ≤ 22) depressive symptoms. Perceived racism was not associated with PTB among women with or without high amounts of perceived stress. CONCLUSIONS Our findings suggest that racism, at least in the form of racial micro aggressions, may not further impact a group already at high risk for PTB (those with severe depressive symptoms), but may increase the risk of PTB for women at lower baseline risk.

We use the Location Affordability Index (LAI) and the newly developed Child Opportunity Index (COI) to assess, for the first time, the tradeoff between neighborhood opportunity and housing/transportation affordability facing low-income renter families in the 100 largest metropolitan areas. In addition to describing the opportunity/affordability relationship, we explore the level of balance between neighborhoods’ relative cost burden and their corresponding opportunity levels to determine whether children of different racial/ethnic groups are more (or less) likely to experience cost-opportunity imbalance. Our multilevel analyses show that housing affordability is largely accounted for by the neighborhood opportunity structure within each metropolitan area. The metropolitan characteristics examined account for only a small proportion of the between-metro variance in the opportunity/affordability gradient for housing, presumably because the neighborhood opportunity structure already reflects metro area factors such as fragmentation and segregation. On the other hand, transportation affordability shows a weaker association with neighborhood opportunity. The COI/LAI association is much weaker for transportation than for housing, and a large part of the variation in the transportation gradient occurs at the metropolitan area level, not the neighborhood level. Sprawl is particularly associated with transportation affordability, with lower sprawl areas having lower transportation-cost burden. We discuss the implications of the empirical findings for defining affordability in housing assistance programs. We recommend that housing policy for low-income renter families adopt an expanded notion of affordability (housing, transportation, and opportunity) and explicitly consider equity (e.g. cost-opportunity imbalance) in the implementation of this expanded affordability definition.

BACKGROUND: Little evidence is available on the effects of incident diabetes or diabetes duration on cognitive aging. METHODS: We evaluated the effects of prevalent and incident diabetes on deteriorations in cognitive function, based on participants (n = 8,671) aged 65+ in the Health and Retirement Study in 2000. Inverse probability weighting was used to account for selective attrition and time-varying confounding of incident diabetes. RESULTS: Prevalent diabetes predicted higher odds of dementia [odds ratio 1.27; 95% confidence interval (CI) 1.03-1.58] and worse memory (-0.06 in z-score units; 95% CI -0.10 to -0.02), but incident diabetes or diabetes duration up to 8 years of follow-up was not predictive. CONCLUSION: Prevalent diabetes predicted lower cognition but not recent onset diabetes.

Perceptions of the residential environment may be associated with preterm delivery (PTD), though few studies exist. Data from the Life-course Influences on Fetal Environments (LIFE) Study (metropolitan Detroit, Michigan, 2009-2011) were used to examine whether perceptions of the current social and physical environment were associated with PTD rates among postpartum African-American women (n = 1,411). Perceptions of the following neighborhood characteristics were measured with validated multi-item scales: healthy food availability, walkability, safety, social cohesion, and social disorder. No significant associations between perceived residential environment and PTD were found in the total sample. However, education significantly modified 4 of the 5 associations (all interaction P's 12 years of education. The PTD rates of women with lower education may be significantly affected by the physical and social residential environment.

BACKGROUND We describe bias resulting from individualized treatment selection, which occurs when treatment has heterogeneous effects and individuals selectively choose treatments of greatest benefit to themselves. This pernicious bias may confound estimates from observational studies and lead to important misinterpretation of intent-to-treat analyses of randomized trials. Despite the potentially serious threat to inferences, individualized treatment selection has rarely been formally described or assessed. METHODS The Moving To Opportunity trial randomly assigned subsidized rental vouchers to low-income families in high-poverty public housing. We assessed the Kessler-6 psychological distress and Behavior Problems Index outcomes for 2,829 adolescents 4-7 years after randomization. Among families randomly assigned to receive vouchers, we estimated probability of moving (treatment), predicted by prerandomization characteristics (c statistic = 0.63). We categorized families into tertiles of this estimated probability of moving, and compared instrumental variable effect estimates for moving on behavior problems index and Kessler-6 across tertiles. RESULTS Instrumental variable estimated effects of moving on behavioral problems index were most adverse for boys least likely to move (b = 0.93; 95% confidence interval: 0.33, 1.53) compared with boys most likely to move (b = 0.14; 95% confidence interval: -0.15, 0.44; P = 0.02 for treatment × tertile interaction). Effects on Kessler-6 were more beneficial for girls least likely to move compared with girls most likely to move (-0.62 vs. 0.02; interaction; P = 0.03). CONCLUSIONS Evidence of individualized treatment selection differed by child gender and outcome and should be evaluated in randomized trial reports, especially when heterogeneous treatment effects are likely and nonadherence is common.

Despite the recent flourishing of mediation analysis techniques, many modern approaches are difficult to implement or applicable to only a restricted range of regression models. This report provides practical guidance for implementing a new technique utilizing inverse odds ratio weighting (IORW) to estimate natural direct and indirect effects for mediation analyses. IORW takes advantage of the odds ratio's invariance property and condenses information on the odds ratio for the relationship between the exposure (treatment) and multiple mediators, conditional on covariates, by regressing exposure on mediators and covariates. The inverse of the covariate-adjusted exposure-mediator odds ratio association is used to weight the primary analytical regression of the outcome on treatment. The treatment coefficient in such a weighted regression estimates the natural direct effect of treatment on the outcome, and indirect effects are identified by subtracting direct effects from total effects. Weighting renders treatment and mediators independent, thereby deactivating indirect pathways of the mediators. This new mediation technique accommodates multiple discrete or continuous mediators. IORW is easily implemented and is appropriate for any standard regression model, including quantile regression and survival analysis. An empirical example is given using data from the Moving to Opportunity (1994-2002) experiment, testing whether neighborhood context mediated the effects of a housing voucher program on obesity. Relevant Stata code (StataCorp LP, College Station, Texas) is provided.