Annals of Epidemiology

Homicide is a leading cause of preventable death in the United States and disproportionately affects Black and Indigenous communities. Structural racism and neighborhood disinvestment are central drivers of these disparities, yet national evidence on whether the association between neighborhood opportunity and homicide risk varies by race/ethnicity remains limited. Using 2020 data from the restricted-use National Violent Death Reporting System linked to Child Opportunity Index (COI 3.0) scores and Census population denominators across 30,077 ZIP codes in 48 states, we estimated age-adjusted log-linked generalized linear models to examine racial/ethnic disparities in homicide rates and their interaction with neighborhood opportunity. Black men experienced homicide rates nearly 20 times those of White men; Indigenous men experienced rates approximately 6 times higher. Higher neighborhood opportunity was independently associated with lower homicide risk across all groups and explained 43-59% of excess risk for Black and Indigenous individuals. Crucially, the association between neighborhood opportunity and homicide was nonlinear and significantly heterogeneous by race/ethnicity, with the steepest rate reductions occurring at the lowest opportunity levels for Black and Indigenous men. These findings suggest that place-based investments in severely deprived communities may yield the greatest reductions in homicide and racial/ethnic health inequities.

Background: Cardiovascular disease (CVD) remains the leading cause of mortality among older U.S. adults, yet the contribution of neighborhood-based structural racism remains inadequately quantified. This study quantifies the association between the Structural Racism Effect Index (SREI) and CVD mortality among adults aged {greater than or equal to}65 years, evaluating how this relationship varies across U.S. geographic regions to identify key areas for intervention. Methods: This ecological study applied a hierarchical Bayesian spatiotemporal framework to 2017-2020 Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) data to estimate the association between SREI and CVD mortality across 3,007 U.S. counties. SREI was modeled continuously and categorically, adjusting for sociodemographic covariates. Population attributable fractions (PAF) and attributable deaths (AD) quantified the potentially preventable burden and its spatial disparities. Results: From 2017 to 2020, approximately 2.79 million CVD deaths were observed, with significant spatial clustering (Moran's I = 0.35, p < 0.001). Each standard-deviation increase in SREI was associated with 13% higher CVD mortality (IRR: 1.13, 95% CrI: 1.12-1.15). A positive dose-response gradient was observed across SREI quartiles, with mortality 24% higher in the highest quartile than in the lowest (IRR: 1.24, 95% CrI: 1.20-1.28). The PAF was 6.94% (95% CrI: 6.13-7.73), corresponding to 193,472 potentially preventable deaths. High exceedance probabilities (>0.95) were concentrated in the Southeast, Appalachia, and the Midwest. Conclusions: Structural racism is a spatially patterned, dose-dependent predictor of older adult CVD mortality, underscoring the need for public health monitoring and neighborhood-based upstream interventions where disease burden is concentrated. Keywords: Structural Racism Effect Index; Neighborhood disadvantage; Cardiovascular Disease Mortality; Bayesian Spatiotemporal Analysis; Population Attributable Fraction; Health Disparities; Health Equity.

Purpose: Population-level lung cancer screening programs require denominators that reflect age, smoking history, geography, and changing eligibility over time. We estimated annual prevalent and 20-year cumulative unique low-dose computed tomography screening eligibility for Maryland residents under alternative screening criteria. Methods: We built a deterministic cohort-cell stock-flow simulation using Maryland county-equivalent jurisdiction projections by age, sex, and race/ethnicity, with ACS socioeconomic/nativity covariates and smoking-history priors for ever-smoked status, pack-years, and quit-years. Scenarios included USPSTF 2013 legacy, USPSTF 2021, ACS 2023/2024, a risk-model-expanded sensitivity, and ever-smoked-only capacity stress tests. Cumulative unique eligibility counted people once at first eligibility rather than summing annual prevalent person-years. Results: Under USPSTF 2021, an estimated 238,346 Maryland residents were eligible in 2026 and 245,326 in 2045. The 20-year cumulative unique denominator was 768,668, whereas naively summing annual prevalent counts produced 4,850,735 person-years, a 6.31-fold overcount. ACS 2023/2024 expanded annual eligibility to 314,616 in 2026 and cumulative unique eligibility to 902,796 by adding remote former smokers. Ever-smoked-only adult eligibility was 1,957,699 in 2026 and 3,383,683 cumulative unique over 20 years. Conclusion: A Maryland statewide screening initiative should plan from cumulative unique eligibility and county-equivalent jurisdiction-specific burden rather than annual prevalence alone. Explicit pack-year and quit-year modeling materially changes statewide and county allocation compared with current-smoking proxy models.

Purpose: Metastatic pancreatic ductal adenocarcinoma (PDAC) portends a poor prognosis. Prior studies have assessed the association of socioeconomic deprivation (SED) in PDAC often with large geographic areas. This study employed a causal framework to characterize neighborhood SED on treatment receipt and survival in metastatic PDAC. Methods: Using the incidence-based Florida Cancer Data System, metastatic PDAC patients diagnosed from 2007-2015 were identified. The Area Deprivation Index, a composite measure of SED that ranks neighborhoods from 1-100 (higher scores = higher deprivation), was used to assess receipt of systemic therapy and overall survival (OS). Exposures and covariates were assessed using descriptive statistics and a causal inference framework. Results: Overall, 9,574 patients met inclusion criteria. 46.6% of patients received systemic therapy, ranging 39.4% to 54% in the highest and lowest SED quartiles, respectively. After adjustment, the lowest quartile had increased odds of systemic therapy relative to the highest (OR 1.93; 95% CI 1.70-2.18). Median OS was 3.8 months for the lowest quartile and 2.4 months for the highest (p = 0.01). Patients in the highest quartile had an estimated 32% higher hazard of death than the lowest (HR 1.32, 95% bootstrap CI 1.20-1.40). Conclusion: In an incidence-based statewide cohort, most patients did not receive treatment for metastatic PDAC and median OS was poor-2.9 months. Using a causal inference framework, higher SED led to lower rates of systemic therapy receipt and worse overall survival in metastatic PDAC. Future research should focus on the mechanisms that shape these findings.

Background: Recreational physical activity has been shown to improve survival among colorectal cancer (CRC) patients. With a growing survivor population, it is necessary to understand whether there are survival benefits across physical activity levels and across sociodemographic and clinical features. Methods: Disparities and Cancer Epidemiology (DANCE) is a population-based cohort of CRC survivors from metro-Detroit and Louisiana. Self-reported moderate and vigorous recreational physical activity was modeled continuously and categorically as none, low (<7.5 MET-hrs/wk), and high (7.5+ MET-hrs/wk). Survival models estimated hazard ratios (HRs) for physical activity with all-cause and CRC-specific survival. Models were stratified by sociodemographic and clinical features; cross-product terms estimated interaction with physical activity. Results: Of 1,107 participants, 26.5% were inactive, 49.1% had low physical activity, and 24.5% had high physical activity. Compared to inactivity, low activity was associated with 44% higher overall survival (HR= 0.56, 95% CI: 0.42, 0.75), and high activity with 66% higher survival (HR=0.34, 95% CI: 0.22, 0.53; P-trend=0.01). Adjustment for comorbidities, quality of life, BMI, and BMI-change did not alter results. Results remained significant for CRC-specific survival (low: HR=0.65, 95% CI: 0.44, 0.96; high: HR=0.45, 95% CI: 0.25, 0.80). Associations were consistent across sociodemographic and clinical features other than BMI and race; survival benefits were larger among White survivors. Conclusion: Any recreational physical activity is associated with longer overall and CRC-specific survival, regardless of sociodemographic or clinical characteristics for the most part. Any physical activity may have survival benefits for CRC survivors, but meeting physical activity guidelines may have the greatest benefit.

Background: Neighborhood disadvantage indices used in public health research and policy include multiple economic, social, and housing items. However, research has failed to question whether it is necessary to include a multitude of economic, social, and housing variables in a single index. The purpose of this work was to examine three different neighborhood indices: a multidimensional disadvantage index, a unidimensional disadvantage index, and a unidimensional affluence index, and examine their performance with respect to distinguishing between healthy and unhealthy census tract neighborhoods in the United States. Methods: The 2022 disadvantage and affluence indices came from the National Neighborhood Data Archive, which are derived from census tract data from the American Community Survey 5-year estimates (2018-2022). The multidimensional disadvantage index included seven economic, social (e.g., single parent households), and housing items; the unidimensional disadvantage index included three poverty and income items; the unidimensional affluence index included 3 items capturing greater social and economic resources. Data on neighborhood health status (census tract prevalence of obesity, diabetes, and coronary heart disease) was obtained from the Population Level Analysis and Community EStimates database for 2022 and linked to the disadvantage and affluence indices for 83,522 census tracts. Contingency tables examined the degree of correspondence in quintiles across the three different indices and the corresponding disease prevalence in each cell. Generalized linear mixed models regressed the disease prevalence variables on index quintiles to determine the predicted prevalence of disease across the disadvantage gradient for each index. Results: Compared to the unidimensional disadvantage and affluence indices, the multidimensional disadvantage index underestimated disease burden in the most disadvantaged census tracts, and overestimated disease burden in the least disadvantaged tracts. Conclusions: Using a disadvantage or affluence index with a more parsimonious set of items would have greater precision in identifying communities at risk for poor health.

Introduction Smoking prevalence remains higher in rural than in urban populations in the United States. To examine recent trends, we assessed state-level differences in cigarette smoking between urban and rural areas from 2018 to 2024. Methods Using repeated cross-sectional data from the Behavioral Risk Factor Surveillance System, we estimated state-specific logistic regression models to examine the relationship between urban-rural county residence and cigarette smoking. Unadjusted models (model 1) included urban-rural county status and year. Subsequent models (model 2) added age, sex, and race/ethnicity. A final model (model 3) included education and an interaction term between urban-rural county status and year to examine whether gaps in urban-rural smoking changed over time. In states with significant interactions, simple effects tests compared trends for urban-rural groups separately. Results Compared to urban adults, rural adults had higher unadjusted odds of cigarette smoking (odds ratio [OR] range:1.07-1.88) in 88.4% (38/43) of states. Adjusting for demographic covariates (model 2) increased the proportion of states with significant marginal effects of rurality to 90.7% (ORs:1.09-1.87). A final model that also controlled for education (model 3) decreased the proportion of states with significant marginal effects of rurality to 60.5% (ORs:1.10-1.54). Among the 14 states with significant interaction terms, the odds of smoking declined faster among urban than rural residents. Conclusion Urban-rural differences in smoking persist across most states. No state showed a reduction in urban-rural disparities over time, and the urban-rural gap widened in 14 states. Demographic variation accounted for some, but not the majority, of observed urban-rural differences.

Documenting and measuring mortality in correctional facilities is essential for understanding the health consequences of incarceration, identifying preventable deaths, and informing policy interventions. We undertook a compilation of publicly available mortality records in state-operated correctional facilities, encompassing data gathered from administrative, nonprofit, and public records. The Harmonized Carceral Mortality Database (HCMD) standardizes decedent characteristics, facility identifiers, locations, dates of death, and causes of death to enable epidemiological analyses of mortality in U.S. prisons, outside of federal reporting. At the time of writing, the HCMD includes 49,682 deaths from at least 1,089 prisons in 50 states, spanning 1996-2024, with regular updates annually. The HCMD supports carceral health research across a range of disciplines from environmental health to sociology to criminology and supports use beyond the scientific community, including journalists, lawyers, and community-based organizers.

The U.S. House's approval of the Sunshine Protection Act has revived the debate over permanent daylight saving time (DST) versus permanent standard time (ST). Health and sleep organizations favor permanent ST because it benefits health, especially for children with rigid school schedules. Further, permanent DST would push school start times to before sunrise in many regions, leading to dark-morning commutes. However, the safety consequences of this shift remain unquantified. Using real school start times for 14 states that have enacted permanent DST legislation, together with local sunrise time, we counted the school days on which students must leave home before sunrise under permanent ST, the current system, and permanent DST. In Washington State, where schools start on average at 08:27, neither permanent ST nor the current system requires any pre-sunrise departure, whereas permanent DST would for most of the winter. Using real school start-time data, permanent DST would add about 35 million child-days of pre-sunrise travel in Washington alone relative to the current system, with similar patterns across the other 13 states. Extrapolated to all U.S. public schools and assuming an 8:00 departure, permanent DST would generate more than 2 billion additional dark-morning commutes each year relative to the current system. Finally, analyzing Seattle traffic collisions, we found that the odds that a crash involved a pedestrian were 143% higher on dark mornings (adjusted odds ratio 2.4). Permanent DST would therefore expose many more children, on many more days, to elevated pedestrian-crash risk, evidence that deserves consideration as the United States chooses a time standard.

Background: The U.S. has the highest health care expenditure globally. Examining long-term national and state-level trends, and benchmarking them against other health systems, can provide important insights for public health planning and policy development. Aim: This study aimed to characterize temporal trends in the burden of bladder cancer, including prevalence, incidence, mortality, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs), and to evaluate state-level disparities and potential long-term effects of health policies. Methodology: Data were obtained from the Global Burden of Disease (GBD) 2021 study. Age- and sex-stratified trends were analyzed and visualized at both national and state levels across the study period. Burden estimates were additionally compared with those of other major health systems, including the European Union, countries with high socio-demographic index, and high-income settings. Results: In 2021, the U.S. recorded age-standardized rates of 8.35 for YLDs (0.33 lower), 3.41 for mortality (0.11 higher), 59.80 for YLLs (6.75 higher), 100.63 for prevalence (6.61 lower), 14.69 for incidence (0.51 lower), and 68.15 for DALYs (6.42 higher) compared to 1990 records. Lowest gender discrepancies across all measures were in 2021 were observed in District of Columbia with male:female ratio of DALYs: 2.4 [1.7, 3.2], mortality: 2.4 [1.8, 3.2], incidence: 2.5 [1.8, 3.4], prevalence: 2.4 [1.8, 3.2], YLDs: 2.4 [1.4, 4.1], and YLLs: 2.4 [1.7, 3.2]. In contrast, North and South Dakota had the highest gender discrepancies: DALYs: 3.9 [3.0, 5.2], incidence: 4.1 [3.1, 5.4], prevalence: 3.9 [3.0, 5.0], and YLLs: 4.0 [3.0, 5.2] and mortality: 4.2 [3.2, 5.6] and YLDs: 3.9 [2.3, 6.3]. Conclusion: Bladder cancer continues to impose a substantial and uneven burden across the U.S. State-level variations, driven by environmental factors, aging populations, and healthcare access gaps, require targeted prevention and improved early detection. Future research should assess the cost-effectiveness of prioritizing prevention over late-stage treatment to optimize healthcare spending.

Purpose: To examine the relative contributions of insurance, county-level poverty, and other socioeconomic factors, as compared with Appalachian geography, to receipt of guideline-concordant therapy for early-stage non-small cell lung cancer (NSCLC) in Appalachian and non-Appalachian Ohio. Methods: Retrospective population-based cohort study using the Ohio Cancer Incidence Surveillance System. We identified adults diagnosed with early-stage NSCLC between 2004 and 2015 (N=26,756). The primary outcome was receipt of guideline-concordant local therapy (surgery or definitive radiation). Rural-urban classification used USDA Rural-Urban Continuum Codes. Multivariable logistic regression and Cox proportional hazards models assessed predictors of treatment and survival, with E-values, race-stratified models, and propensity score weighting as sensitivity analyses. Findings: Median age was 71 years; 50.3% were male, 83.8% non-Hispanic White, and 20.4% Appalachian. Overall, 83.6% received guideline-concordant local therapy (59.6% surgery, 24.0% radiation). In adjusted analysis, Medicaid (adjusted odds ratio [OR] 0.53, 95% confidence interval [CI] 0.44-0.63; adjusted risk ratio [RR] 0.94, 0.91-0.96), county-level poverty >20% (OR 0.77, 95% CI 0.68-0.87; RR 0.96, 0.95-0.98), and unmarried status were independently associated with lower therapy receipt, whereas Appalachian residence was associated with modestly higher receipt (OR 1.17, 95% CI 1.06-1.29; RR 1.02, 1.01-1.04). Therapy rates converged across regions over the study period (year x Appalachian interaction p<0.001). Mortality was independently associated with lack of local therapy (adjusted hazard ratio [HR] 4.33, 95% CI 4.10-4.56), Medicaid (HR 1.25, 95% CI 1.14-1.37), and poverty >20% (HR 1.13, 95% CI 1.07-1.20). Conclusions: Socioeconomic factors, particularly Medicaid insurance and county-level poverty, were the patient characteristics most strongly associated with lower receipt of guideline-concordant therapy, whereas Appalachian residence was not a barrier. Findings support targeted interventions addressing insurance-related and poverty-related barriers to lung cancer care in high-poverty communities regardless of geographic designation.

Introduction: Breast, cervical, and colorectal cancer screening guidelines changed substantially between 2010 and 2019. We examined trends in the annual utilization of these screenings among commercially insured enrollees in the United States from 2010 to 2019 by age group, geographic region, and screening modality. Methods: We conducted a retrospective, serial cross-sectional analysis of the MarketScan Commercial Claims Database from 2010 through 2019, comprising approximately 141.2 million privately insured enrollees. Annual screening rates, defined as the proportion of eligible enrollees receiving a given test within each calendar year, were estimated for cervical, breast, and colorectal cancer using procedure codes, stratified by age group, screening modality, and geographic residence. These reflect annual utilization rather than up-to-date (guideline-concordant) screening. Temporal trends were evaluated using two-sided Poisson regression, and urban-rural disparities in 2019 were assessed using multivariate generalized estimating equations. Results: Cancer screening utilization remained stagnant or declined across all three cancer types over the study period. Among women aged 30-64 years, cervical cytology alone declined substantially from 28.2% in 2010 to 8.8% in 2019, while co-testing increased from 11.4% to 20.3%. Screening mammography among women aged 50-64 showed minimal change, remaining stable at 45.7% in 2010 and 45.8% in 2019. Colorectal cancer screening across enrollees aged <64 decreased modestly from 7.7% in 2010 to 6.5% in 2019, with a more pronounced decline among adults aged 45-49 years. Across all three cancer types, screening utilization was higher among urban residents than rural residents, with incidence rate ratios ranging from 1.02 to 1.05 in 2019. Conclusions: Utilization of cervical, breast, and colorectal cancer screening among commercially insured adults did not improve between 2010 and 2019. Persistent urban-rural disparities highlight ongoing gaps in preventive care delivery. Targeted interventions may help improve screening utilization, particularly in rural and underserved populations.

Introduction: Early childhood vision screening is critical for detecting amblyopia and other vision-threatening conditions. Despite screening recommendations during well-child visits, rates remain low. Red reflex assessment is recommended to identify serious ocular pathology, yet its use in primary care is not well described. We examined rates and drivers of vision screening in pediatric primary care. Methods: We conducted a retrospective review of electronic health records for children 3 to 5 years attending well-child visits in 2022 in one of three representative primary care clinics within a university health system. Outcomes were documented red reflex and functional vision tests. We evaluated associations with patient demographics and clinic site using multivariable logistic regression Results: Among 1,003 visits, 21.1% (n=212) had a documented red reflex assessment, and 60.8% (n=610) a functional vision test. Younger children (ages 3 and 4 vs. 5 years) had higher odds of red reflex assessment [adjusted odds ratio (aOR) 9.00 and 8.64], and lower odds of a functional vision (aOR 0.47 and 0.59) test. Females had higher odds of red reflex assessment (aOR 1.53). Other/Multiracial children had lower odds of red reflex assessment than Non-Hispanic White children (aOR 0.48). Screening rates varied significantly by clinic site Conclusions: Visual function and red reflex assessment are inconsistently performed in pediatric primary care, with particularly low rates of red reflex documentation. Screening rates varied between clinics and were affected by age. These findings highlight missed opportunities for early detection of vision-threatening conditions and identify targets for improving adherence to pediatric vision screening recommendations

Background Alcohol-associated injury is a leading cause of emergency department (ED) utilization in the United States and a clinically important driver of preventable morbidity across the adult lifespan. Prior surveillance research has characterized how the rate and severity of alcohol-associated injury vary by patient age, but whether the seasonal timing of injury risk is equally predictable across age groups (a question directly relevant to the timing of clinical screening intensification and public health intervention) has not been formally tested. Methods We conducted a retrospective surveillance analysis of 45,876 alcohol-associated ED visits among adults aged 18 years and older, identified from the National Electronic Injury Surveillance System (NEISS), 2019-2025 (weighted national estimate: 2,092,319 visits), using the structured Alcohol_Involved indicator introduced into NEISS case abstraction in 2019. Patients were stratified by sex and five age groups (18-24, 25-34, 35-49, 50-64, and [&ge;]65 years). Single-harmonic cosinor (Poisson) regression was used to estimate the seasonal peak day of injury risk (acrophase) for each stratum. To assess reliability, we performed leave-one-year-out jackknife resampling (seven iterations per group), case-resampling bootstrap confidence intervals (1,000 iterations), and likelihood-ratio tests of seasonal-phase interactions. Results Peak injury timing differed significantly across age groups (X^2 [8] = 2356.2, p < .0001). Adults aged 25-64 years showed a highly reproducible early-to-mid-July peak, with jackknife estimates shifting [&le;]14 days when any single study year was excluded. Adults aged [&ge;]65 years showed significant seasonal variation annually (all p < .0001, amplitude comparable to younger groups) but a pooled peak estimate that shifted by up to 100 days across jackknife iterations. Sex-stratified analyses revealed that this instability was driven entirely by females aged [&ge;]65 years (jackknife range: 332 days, peak consistently in late October through early January) rather than males aged [&ge;]65 (jackknife range: 31 days, peak consistently in early August). Hospital admission rates increased monotonically with age from 9.0% (18-24 years) to 31.8% ([&ge;]65 years). Conclusions Alcohol-associated injury follows a reproducible, calendar-stable summer seasonal pattern in adults aged 25-64 years. Among adults [&ge;]65 years, the previously reported temporal instability is concentrated in the female subgroup, whose seasonal injury risk does not converge on a fixed calendar window. These findings suggest that fixed-calendar prevention and screening strategies are well suited to working-age adults and older men, but older women may require a year-round, individually tailored approach. Keywords: Alcohol-related injury; Emergency department; Seasonality; Age factors; Sex differences; Injury surveillance; Cosinor analysis; Older adults

Exposure to higher levels of ambient air pollution during pregnancy has been linked to multiple adverse pregnancy outcomes. However, studies on acute exposures and reduced gestation length have reported inconsistent findings. This project aims to examine the acute association between ambient air pollution and preterm (28-36 gestational weeks) or early-term (37-38 gestational weeks) births. Daily concentrations of 12 air pollutants, based on bias-corrected numerical model outputs, were linked to vital records of singleton live preterm and early-term births from 2005-2017 in California, Florida, Georgia, Kansas, Nevada, New Jersey, North Carolina (2005-2015), and Oregon. Under a time-stratified case-crossover design, odds ratios (OR) were estimated via conditional logistic regression with adjustment for risks among ongoing pregnancies, meteorology, time trends and federal holidays. We estimated cumulative associations up to a 6-day lag using distributed lag models. Risk estimates per interquartile range (IQR) increase in exposure were pooled across states using inverse-variance weighting. Our study included 1,085,162 preterm and 3,901,185 early-term births. We observed positive associations between 0-2 day cumulate exposure to several air pollutants and early-term births, including NO2 (OR: 1.0023, 95% CI:1.0010, 1.0037 per 7.1 g/m3 increase), PM2.5 (OR=1.0022, 95% CI: 1.006, 1.0038 per 4.6 g/m3 increase), PM2.5 organic carbon (OR= 1.0026, 95% CI: 1.0013, 1.0039 per 1.7 g/m3 increase) and PM2.5 elemental carbon (OR=1.0025, 95% CI: 1.0014, 1.0035 per 0.26 g/m3 increase). Associations with preterm birth were mostly null. In conclusion, we found positive associations between short-term air pollution exposure, including PM and major PM2.5 components, and risks of early-term birth.

Background: Endometrial cancer incidence and mortality are increasing, particularly among Black women and for aggressive subtypes. Allostatic load (AL), a composite measure of physiologic dysregulation across metabolic, cardiovascular, and immune systems, varies by racial category and tumor subtype in other cancers. Endometrial cancer is strongly associated with obesity, and it is unknown whether AL scores maintain sufficient heterogeneity to evaluate differences across subgroups or with clinical outcomes. Objective: To describe the performance of AL scoring in endometrial cancer patients and examine associations with tumor characteristics (grade/histology) and survival outcomes. Methods: We evaluated AL among 398 participants newly diagnosed with endometrial cancer. AL score was calculated by assigning 1 point for each ''high-risk'' value (by clinical reference range or distribution-based) for 15 biologic variables for vital signs, anthropometrics, blood-based biomarkers, and medical comorbidities. Results: Distribution-based thresholds for variables were used to preserve heterogeneity in this obesity-dominant context. Overall, 68.7% of Black women had high AL compared to White (56.7%), Hispanic (56.7%), and other race (32.3%) women. Decision tree analyses revealed grade-dependent associations between AL and survival. For women with low-grade tumors, higher AL was associated with poorer overall survival. For high-grade tumors, intermediate AL ([&ge;]4, <8) were associated with shortest overall survival. Black women with low-grade disease experienced shorter progression-free survival regardless of AL. Conclusions: AL scoring maintains heterogeneity despite high obesity prevalence in endometrial cancer. Varying relationships between AL and survival by tumor grade and ethnoracial group suggest cumulative physiologic burden and social/structural factors may jointly shape endometrial cancer disparities.

Abstract Background Neighborhood socioeconomic disadvantage may contribute to inequities in access to dental care by influencing the geographic distribution of providers. The Area Deprivation Index (ADI) is a validated measure of neighborhood deprivation, but its association with dental workforce availability has not been examined statewide in California. This study evaluated the relationship between neighborhood deprivation and dental provider density across California ZIP Code Tabulation Areas (ZCTAs). Methods We conducted a cross-sectional ecological study of California ZCTAs using publicly available data from the National Plan and Provider Enumeration System (April 2026), the Neighborhood Atlas 2023 ADI, and 2024 U.S. Census population estimates. Active dental providers were linked to ZCTAs and provider density was calculated per 10,000 residents. ADI was aggregated to the ZCTA level using the median ADI national percentile. Negative binomial regression was used to assess the association between ADI and dental provider density, with population included as an offset. Secondary analyses examined California-specific ADI quartiles, dental deserts, and specialist versus general dentist availability. Results The final analytic sample included 1,426 California ZCTAs representing 39,016,384 residents and 37,945 active dental providers. Greater neighborhood deprivation was significantly associated with lower dental provider density. Each one-percentile increase in ADI corresponded to a 1.8% reduction in provider density (incidence rate ratio [RR] 0.9823, 95% confidence interval [CI] 0.9799-0.9847; p < 0.001). Compared with the least deprived quartile, the most deprived quartile had 61% fewer dental providers (RR 0.39, 95% CI 0.34-0.45; p < 0.001). Overall, 15.9% of ZCTAs contained no active dental providers, increasing from 6.8% in the least deprived quartile to 31.1% in the most deprived quartile. Specialist availability demonstrated an even steeper deprivation gradient, with specialist density declining by 86% between the least and most deprived quartiles.

Indiana still faces significant health challenges, ranking among the least healthy U.S. states due to high obesity rates, mental health issues, and other chronic conditions. These disparities are closely linked to inequities in healthcare access, which are largely shaped by social determinants of health. Using data from the Social Vulnerability Index and County Health Rankings and Roadmaps, this study analyzes trends in obesity, mental health, and premature death across Indiana counties before, during, and after the COVID-19 pandemic. Descriptive statistics, correlation analyses, and Negative Binomial regression models were used to evaluate county-level disparities. In 2018, higher rates of uninsured, obese, and physically inactive populations were associated with increased premature death. In 2020, diabetes, smoking, and alcohol consumption were significant factors. By 2022, unemployment, education, obesity, insurance, exercise access, and mental health provider availability were associated with premature death. Findings indicate that socially vulnerable counties experienced amplified health impacts, with obesity rising most sharply where exercise infrastructure was limited and poor mental health days increasing across all counties. These results highlight persistent service gaps and the critical need for targeted investments in recreational infrastructure and mental healthcare. Future research should examine policy influences and causal relationships to inform equity-focused interventions.

Background: Colorectal cancer (CRC) disproportionately affects non-Hispanic Black (NHB) Americans compared to Non-Hispanic White (NHW), with more cases arising before age 50. Racial disparities in outcomes reflect complex interactions among healthcare access, socioeconomic factors, and structural racism, yet analyses linking individual-level data for these factors to survival remain limited. Methods: We examined overall and CRC-specific survival among NHB and NHW patients diagnosed between 2013 and 2022 enrolled in the Disparities and Cancer Epidemiology (DANCE) cohort, a population-based study of CRC in metropolitan Detroit and Louisiana. Multivariable Cox regression and competing-risks models were used to assess the roles of race, age of onset, neighborhood deprivation, and stage on survival outcomes. Results: Among 1,019 CRC cases (57% NHB, 43% NHW), NHB patients were more likely to reside in high-deprivation neighborhoods, report lower household incomes, and present with right-sided tumors, though stage at diagnosis did not differ by race. In multivariable analysis, stage was the strongest predictor of survival, while neighborhood deprivation (per 10-unit ADI increase: HR = 1.14) was independently associated with worse survival; NHB race was not significantly associated with survival after adjustment. Younger age at diagnosis was associated with a survival advantage in regional-stage disease but paradoxically with worse survival in distant-stage disease, and higher deprivation predicted worse survival in both local and distant but not regional stage. Conclusion: Our study shows that socioeconomic factors, as measured by ADI and household income, accounts for some, but not all, of the disparities in survival between NHB and NHW CRC cases.

Greenspace has been associated with a wide range of health outcomes and conditions related to functional limitation and disability. Yet less is known about how the spatial morphology of greenspace relates to disability prevalence across different stages of the life course. This study examines associations between greenspace morphology and disability prevalence among children, working-age adults, and older adults in urban census tracts across the contiguous United States. Using national land-cover data, we quantified morphological metrics at the census-tract level, including greenspace percentage, density, mean size, connectedness, shape complexity, inter-greenspace distance, and diversity. These indicators were linked with age-specific disability prevalence obtained from the American Community Survey. Spatial lag regression models were used to account for spatial dependence while adjusting for socio-demographic and contextual characteristics. Across age groups, higher greenspace percentage was consistently associated with lower disability prevalence (children: {beta} = -0.081, 95% CI: -0.096 to -0.066; adults: {beta} = -0.804, -0.858 to -0.750; older adults: {beta} = -1.132, -1.250 to -1.013). Among children, patch density ({beta} = -0.045, -0.061 to -0.029), mean patch area ({beta} = -0.029, -0.040 to -0.018), connectedness ({beta} = -0.051, -0.069 to -0.032), diversity ({beta} = -0.036, -0.051 to -0.020), and inter-greenspace distance ({beta} = 0.056, 0.039 to 0.073) were all associated with disability prevalence, whereas shape complexity was not ({beta} = 0.004, -0.010 to 0.018). Among working-age adults, associations were observed for mean area ({beta} = -0.023, -0.090 to -0.002), connectedness ({beta} = -0.127, -0.243 to -0.011), shape complexity ({beta} = -0.123, -0.174 to -0.072), diversity ({beta} = -0.146, -0.201 to -0.091), and inter-greenspace distance ({beta} = 0.151, 0.059 to 0.242), whereas patch density was not significantly associated with disability prevalence ({beta} = -0.013, -0.048 to 0.022). In older adults, all examined greenspace morphology metrics showed significant associations with disability prevalence, including patch density ({beta} = -0.445, -0.842 to -0.049), diversity ({beta} = -0.126, -0.188 to -0.065), and inter-greenspace distance ({beta} = 0.455, 0.409 to 0.501). Overall, the findings suggest that higher greenspace percentage, larger patch size, greater connectedness, greater diversity, and more spatially clustered greenspace distributions are associated with lower disability prevalence across the life course, although the strength and consistency of these associations varied across age groups. The study provides national-scale evidence for incorporating greenspace morphology into urban planning and public health strategies to support more inclusive and health-supportive urban environments.