Volume 11, Issue 4 - Special issue: Break the cycle of environmental health disparities (VI) in memory of Allen C. Crocker: Editors: I. Leslie Rubin, Robert J. Geller, Janice Nodvin, Michele Marcus, Maeve Howett and Joav Merrick

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Dental caries are of serious concern as increasing numbers of cases of early childhood caries are seen. Oral hygiene and the development of dental caries is a challenging issue to address in any child. However, children in lower socioeconomic groups are disproportionately affected when compared with their higher-income peers. Low-income children are found to be twice as likely to have dental problems, with a reported prevalence of up to 50%. Several environmental factors have been found to play a role in this difference, including passive smoke exposure, lead exposure, and poor nutritional intake. While lead exposure and nutrition have been studied extensively, the association between passive smoke exposure and dental caries in children is less well known. This review will consider these environmental risk factors, focusing primarily on passive smoke exposure and its association with the development of dental caries. We will also propose potential strategies, on the basis of a comprehensive understanding of both existing published research and community-based interventions, as a means of addressing the health disparities that contribute so dramatically to this problem.

Neglected tropical diseases (NTDs) are a group of tropical infections that are endemic in the poorest regions of the world. Often chronic and disabling, NTDs occur most commonly in the setting of extreme poverty, especially among the rural poor and some disadvantaged urban populations. These diseases affect more than 1 billion individuals worldwide, and children are the most vulnerable. About 70% of deaths from NTDs occur in children 14 years old and younger. Solutions toward reducing the burden of NTDs include preventive chemotherapy, vector control, and improvements in sanitation and housing. In the area of preventive medicine, few drugs are available for NTDs, and in general, the diseases are under-researched. Despite the tremendous potential benefits of vaccines, pharmaceutical companies have little financial incentive to invest in the research and development of health technologies that will only benefit poor people in poor countries. Currently, most projects to combat NTDs focus on sanitation and vector control. Although these methods hold great promise, the difficulty of obtaining sustained funding limits their efficacy. Although effective during implementation, when interventions are not sustained, disease transmission returns. To make a lasting impact, it is essential to institutionalize successful existing programs and partnerships. A treaty addressing NTDs would build on existing alliances and international agreements to ensure a long-term, legal commitment to reducing the tremendous global burden of NTDs.

Environmental tobacco smoke (ETS) exposure is an international problem. Parental smoking is the primary exposure for children. While the adverse health effects of secondhand smoke to children are well recognized and used to educate caregivers, the concept of “third-hand smoke” (THS) and its use as an educational tool has been less studied. The purpose of this project was to determine the impact of brief THS intervention on smoking behaviors of caregivers of children seen in an urban pediatric ED. A convenience sample of children <36 months with caregivers who smoke brought to a pediatric ED was recruited. Consented caregivers were randomized to a control group who received routine education or intervention group who received brief THS education. Follow-up phone assessments were completed to evaluate smoking behavior changes. Of 40 caregivers analyzed, 85% were female, 72% were non-white, and mean age was 29 years. Results revealed the treatment group was more likely to change smoking policies (OR 2.0, 95% CI 0.166–24.069), reduce the number of cigarettes (OR 4.88, 95% CI 0.785–30.286), or quit smoking (OR 1.12, 95% CI 0.346–3.590). This study demonstrated that a brief THS intervention in our sample influenced smokers to change smoking behaviors. These changes would ultimately decrease ETS exposure to children and its adverse health effects. With the limitations of small sample size and high loss to follow-up, the study does not show statistical significance for generalizability.

In this pilot study, we assessed the nutritional risk factors and depression among a group of 15 first-time, low-income mothers. Results showed that a majority of the participants reported multiple nutritional risk factors and diets that did not meet standard dietary recommendations for pregnancy. Although our sample was too small to examine formally the relationship between nutritional risk and depression, those with depression symptoms were among those with the highest nutritional risk.

Exposure to inorganic arsenic through drinking water has been a major public health problem around the world. This study was designed to assess the effectiveness of the improvement of water supply in endemic regions of China and the demographic factors associated with arsenic exposure in children. Data on water arsenic levels from different monitoring sites in endemic regions before and after the improvement of drinking water supply were obtained from the Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention. Arsenic levels in urine were measured in children aged 8–12 years in endemic villages where the drinking water supply was improved. The results demonstrated that the improvement of drinking water supply by the Chinese Government led to the improvement of water quality for residents living in endemic regions. The median arsenic levels in children’s urine after improvement in water supply showed significantly lower levels than in children living in the village that did not receive improved water supply. However, a wide range of urinary arsenic levels was seen among the study participants, which could reflect the disparities in genetic and socioeconomic factors. Based on the limited demographic information obtained for the study population, no conclusions can be drawn in this study regarding the effect of socioeconomic factors on arsenic exposure in children.

Poverty and socioeconomic disadvantage are associated with environmental inequalities such as exposure to hazardous air pollutants. Children from low-income communities living in highly polluted cities tend to exhibit higher rates of depression, anxiety, and attention disorders. Early exposure to pollution may play a part in this trend. A postulated mechanism for this is that maternal exposure to traffic-related air pollutants can trigger an immune response in the mother. This inflammatory response can be transferred to the fetus via the placenta, with resultant effects on brain and lung inflammation. Our study used a murine model to examine the effects of prenatal and early postnatal toxin exposure on neurocognitive outcomes. Behavioral tests were conducted on cohorts treated with traffic-related air pollutants, ozone, and diesel, to assess if multiple agent exposures had synergistic effects on neurocognitive development. Animals exposed to the pollutants developed maladaptive responses later in life. Our findings show that perinatal brain development is susceptible to the toxic effects of air pollution. Despite the adverse effects of perinatal exposure on outcome, enriching the prenatal, postnatal, and childhood environments may break the cycle of disadvantage. Educational enrichment programs aimed at enhancing specific neurocognitive functions offer the opportunity to bridge disparities in mental health, academic achievement, and cognition and overcome the adverse environmental influences.

An ecological study was conducted of fetal death and birth outcomes in Georgia counties from 1994 to 2006 to examine the effects of area-level social and economic factors upon the occurrence of stillbirths. Fetal death and live birth certificate data were merged with census and racial residential segregation data from census data sources and the Population Studies Center of the University of Michigan. Stillbirths were defined as fetal death with gestation of >20 weeks. Analysis was limited to 1,419,767 birth outcomes (12,114 stillbirths and 1,407,653 live births) among non-Hispanic black (N=4748 stillbirths) and white (N=7366 stillbirths) mothers. Multivariate logistic regression, using a generalized estimating equation (GEE) to account for the clustering of individuals within counties, was used to estimate the odds of having a stillbirth among the black and white mothers of Georgia counties, controlling for their individual-level attributes. There was an interaction between individual race and residential segregation. Among white mothers, increased county segregation was associated with decreased stillbirth risk (highest vs. lowest quintile of segregation, aOR=0.82, 95% CI: 0.71, 0.94), while for black mothers, stillbirth risk increased in more segregated counties (highest vs. lowest quintile of segregation, aOR=1.15, 95% CI: 0.99, 1.33). The black-white racial disparity in stillbirth risk rose from an aOR of 1.67 (95% CI: 1.52, 1.83) for low-segregation counties to an aOR of 2.35 (95% CI: 2.16, 2.55) for high-segregation counties. These results speak: of the enduring nature of race in shaping African Americans’ life chances, specifically for this study with regard to the viability of black infants.

Despite advancements in prenatal care and technologies, significant disparities in pregnancy outcomes remain. Non-Hispanic Black women and their infants suffer a disproportionately high burden of poor pregnancy outcomes in comparison to non-Hispanic White women. Race and socioeconomic status alone have failed to account for these persistent disparities; increasing evidence has associated environmental and social factors with poor pregnancy outcomes. This project investigates the joint contributions of environmental and psychosocial factors to the cycle of disparities in pregnancy outcomes in the Healthy Pregnancy, Healthy Baby prospective cohort study of pregnant women in Durham, North Carolina. The results indicate that women who are disadvantaged are exposed to multiple environmental and psychological stressors throughout their pregnancy, some of which are in turn related to the pregnancy outcomes of some of these women. Suggestions on breaking the cycle of disadvantage and disability are discussed.

Asthma and environmental asthma triggers continue to affect the quality of life of children, who are more affected by the disease than adults. This is especially true for African American children. The purpose of this study is to use peer teaching and dramatic play to increase asthma awareness in African American children, ages 5–17 years. A non-experimental design was used for this study. A 3-week intervention was implemented in three groups of children: elementary school, middle school, and high school. Designated peer leaders were tasked to take key points from the facilitated discussion about asthma and environmental asthma triggers and to create original skits, games, and other types of dramatic play to convey the key messages to the younger groups, and eventually their parents and the church community. As a result of the intervention, statistically significant increases in asthma awareness were demonstrated. Findings from this study suggest that to break the cycle of environmental health disparities in children who are vulnerable as a result of social and economic disadvantage, health practitioners and scientists must be culturally competent and seek to use innovative approaches to raise awareness in targeted communities.

This qualitative study was aimed at exploring the relation between the 2008 economic recession and the risks associated for marginalized communities, schools, and students. A total of eight school employees from two schools were interviewed regarding their experiences during the recession. Each of the eight participants reported increased risks and high impact to their students as a result of their experience of the 2008 recession. The results suggest that each of the schools encountered increased requests for social non-academic support from students and their parents, as well as changes in the school academic support. Participants mentioned impacts most frequently in three areas, changes in responsibility, changes in resources, and social and academic impact. Each of these areas appeared to correspond with greater responsibility and multi-function demands among the participants.

Although it is well recognized that substance abuse during pregnancy is detrimental to maternal and fetal health, limited research to date has addressed the relationship between substance use and birth outcomes among women experiencing homelessness. This study investigates the association between women experiencing homelessness and a history of substance use and reported child health outcomes in one southeastern city. Seventy-three clients from a shelter and rehabilitation facility in Atlanta, Georgia, were surveyed, including data for the children of 56 participants. The prevalence of multiple child health outcomes among women with and without substance use during the prenatal period were compared to national or state normative levels. Exposure to substance or tobacco use during pregnancy was significantly higher among mothers who were single, less educated, unemployed, or widowed. Children of substance-using mothers in the sample had more than 1.5-fold increased prevalence of functional problems than children experiencing homelessness alone. Comparatively, no children of mothers without prenatal substance exposure reported physical, cognitive, development, and/or speaking problems. Prenatal substance abuse compounded by other aspects of homelessness results in greater health problems for children than reported previously. An increased focus on preventing prenatal exposure among pregnant women experiencing homelessness may be warranted.