June 17, 2016
Supervisory Committee:
Linda B. Cottler, PhD, MPH, FACE, Chair
Xiaohui Xu, PhD, MD, MA, Former Chair
Cindy A. Prins, PhD, MPH, CIC, CPH, Member
Barron H. Henderson, PhD, Member
Xiaomin Lu, PhD, Member
Public Health Significance of HDP
Theoretical Framework
Air Pollution and HDP
Neighborhood SES and HDP
Racial Disparities in HDP
Knowledge Gap
Research Objectives
A common pregnancy complication (up to 10%)
Classified into four categories:
Linked to adverse health outcomes in both mothers and infants
A Socio-Ecological Model (SEM) of Factors Influencing HDP
Air pollution and adverse birth outcomes
Air pollution and hypertension in the general population
Potential biological mechanisms:
Existing literature:
Neighborhood SES and adverse birth outcomes
Neighborhood SES and hypertension in the general population
Existing literature:
Social differences
Different SES categories examined
A variety of indices used in previous studies
Hard to interpret the results and to guide interventions
Increasingly large racial disparities in HDP
Racial residential segregation
Little is known about the factors contributing to racial disparities in HDP
Very few studies and inconsistent results
Critical window of exposure to air pollution during pregnancy is unknown
Individual neighborhood SES characteristic predictive of HDP is unknown
How neighborhood environment contributes to racial disparities in HDP is unknown
O3 is the air pollutant of the greatest concern to the state of Florida
Recent meta-analyses suggest an overall positive association between ozone and HDP
Limitations in existing literature:
Data source: Florida Vital Statistics Birth Record data
All women gave live births in Florida during 2005-2008 (n=917,788)
Residential addresses which could not be geocoded (n=108) or outside Florida (n=4,632) were excluded.
Conception date between January 1, 2005 and December 31, 2007 (n=691,011)
Exclude non-singleton deliveries (n=21,609), pre-pregnancy hypertension (n=10,590), birthweight <500g or >5,000g (n=621), or with a gestational age <26 weeks (n=2,662).
A total of 655,529 women were included.
Diagnoses of prepregnancy hypertension, gestational hypertension or preeclampsia, and eclampsia were collected
The restricted definition of HDP was used in this study, which only includes:
Data: The hierarchical Bayesian space-time statistical modeled (HBM) data from the National Environmental Public Health Tracking Network (2005-2008)
Exposure windows:
Age: <20, 20-24, 25-29, 30-34, 35-39, or ≥40 years old
Race/ethnicity: non-Hispanic White, non-Hispanic Black, Hispanic, or others
Education: <high school, high school or equivalent, or >high school
Marital status: married or not married
Pregnancy smoking status: yes or no
Pre-pregnancy BMI: underweight, normal, overweight, or obese
Season of conception: warm (June-November) or cool (December-May)
Year of conception: 2005, 2006, or 2007
Predefined windows of exposure:
Identification of critical window of exposure:
Compared with women without HDP, HDP cases were:
31,362 (4.8%) women had HDP
Women with HDP had a higher exposure to O3 compared with those without HDP during the three pre-defined exposure windows
Positive associations between HDP and O3 exposure across the first 24 weeks of gestation, with higher odds of HDP observed in early pregnancy
A consistent pattern of elevated odds of HDP with increased exposure to O3 during the first two trimesters.
Early pregnancy was the most critical window for O3 exposure during pregnancy.
Consistent with pooled estimates from meta-analyses
Potential biological mechanism:
The elevated odds ratio observed in early pregnancy:
Implications for health interventions:
Strengths:
Limitations:
Socioeconomic status (SES) is an important determinant of health.
Low neighborhood SES has been linked to increased risks of hypertension in the general population and adverse birth outcomes.
Limitations in existing literature:
To examine the association between neighborhood socioeconomic status and hypertensive disorders of pregnancy.
Hypothesis 2.1: Neighborhood socioeconomic status assessed by the Standardized Neighborhood Deprivation Index is associated with hypertensive disorders of pregnancy.
Hypothesis 2.2: Individual neighborhood socioeconomic characteristics such as income and poverty are predictive of hypertensive disorders of pregnancy.
Data source: Florida Vital Statistics Birth Record data
All women gave live births in Florida during 2005-2008 (n=917,788)
Residential addresses which could not be geocoded (n=108) or outside Florida (n=4,632) were excluded.
Conception date between January 1, 2005 and December 31, 2007 (n=691,011)
Exclude non-singleton deliveries (n=21,609), pre-pregnancy hypertension (n=10,590), birthweight <500g or >5,000g (n=621), with a gestational age <26 weeks (n=2,662), or missing NDI (n=3,581).
A total of 651,948 women were included.
Diagnoses of prepregnancy hypertension, gestational hypertension or preeclampsia, and eclampsia were collected
The restricted definition of HDP was used in this study, which only includes:
Data: The 2006-2010 American Community Survey
Neighborhood Deprivation Index (NDI):
Age: <20, 20-24, 25-29, 30-34, 35-39, or ≥40 years old
Race/ethnicity: non-Hispanic White, non-Hispanic Black, Hispanic, or others
Education: <high school, high school or equivalent, or >high school
Marital status: married or not married
Pregnancy smoking status: yes or no
Pre-pregnancy BMI: underweight, normal, overweight, or obese
Season of conception: warm (June-November) or cool (December-May)
Year of conception: 2005, 2006, or 2007
Urbanity: urban or rural
NDI:
Determination of predictive neighborhood SES characteristics:
Women living in neighborhoods with lower SES had higher odds of HDP.
The following neighborhood characteristics are predictive of HDP:
Consistent with previous studies:
Implications for health interventions:
Strengths:
Limitations:
The burden of HDP falls disproportionately on African Americans.
There is an increasing trend of racial disparities in HDP.
Neighborhood environmental factors such as racial residential segregation, urbanity, neighborhood SES, and O3 exposure are potential mediators for racial disparities in HDP.
Few studies has directly addressed how neighborhood environmental factors contribute to the racial disparities in HDP.
To examine the racial disparities in hypertensive disorders of pregnancy and how neighborhood environmental factors mediate the pathways.
Hypothesis 3.1: African American women have higher risks of hypertensive disorders of pregnancy compared with non-African Americans.
Hypothesis 3.2: The association between race and hypertensive disorders of pregnancy is mediated by neighborhood environmental factors including O3 exposure during pregnancy, neighborhood socioeconomic status, urbanity, and racial residential segregation.
Data source: Florida Vital Statistics Birth Record data
All women gave live births in Florida during 2005-2008 (n=917,788)
Residential addresses which could not be geocoded (n=108) or outside Florida (n=4,632) were excluded.
Conception date between January 1, 2005 and December 31, 2007 (n=691,011)
Exclude non-singleton deliveries (n=21,609), pre-pregnancy hypertension (n=10,590), birthweight <500g or >5,000g (n=621), with a gestational age <26 weeks (n=2,662), or missing race/ethnicity (n=14).
A total of 655,515 women were included.
Diagnoses of prepregnancy hypertension, gestational hypertension or preeclampsia, and eclampsia were collected
The restricted definition of HDP was used in this study, which only includes:
The spatial measure of neighborhood level racial isolation developed by Anthopolos et al. 2011.
Ozone: exposure during the first two trimesters using the HBM data
NDI: the first factor loadings from the PCA on 17 variables
Urbanity: 2010 Census
Age: <20, 20-24, 25-29, 30-34, 35-39, or ≥40 years old
Race/ethnicity: non-Hispanic White, non-Hispanic Black, Hispanic, or others
Education: <high school, high school or equivalent, or >high school
Marital status: married or not married
Pregnancy smoking status: yes or no
Pre-pregnancy BMI: underweight, normal, overweight, or obese
Season of conception: warm (June-November) or cool (December-May)
Year of conception: 2005, 2006, or 2007
Determination of racial disparities in HDP:
Mediation analyses to determine how neighborhood environmental factors contribute to racial disparities in HDP:
The IORW avoids the difficulties of specifying a model for the joint conditional density of multiple mediators by using weights to indicate the relationship between exposure and multiple mediators.
Standard errors for the estimated direct and indirect effects were derived by using 1,000 bootstrap replications.
African American women had significantly higher odds to have HDP compared with non-African American women.
35% of racial disparities in HDP can be explained by the differential exposure to neighborhood environmental factors, including ozone exposure, urbanity, neighborhood SES, and racial residential segregation, between African American women and non-African American women.
Consistent with existing literature:
Implications for health interventions:
More efforts should be given on neighborhood-level interventions such as:
The smart growth by The American Planning Association
The community revitalization initiatives
“Environmental justice” interventions
Strengths:
Limitations:
Determination of Association between O3 Exposure during the Three Pre-defined Exposure Windows of Pregnancy and HDP
Identification of Critical Windows of O3 Exposure during Pregnancy for HDP
Determination of Association between Neighborhood SES and HDP
Identification of Individual Neighborhood Socioeconomic Characteristics Predictive of HDP
Identification of Racial Disparities in HDP between African Americans and Non-African Americans
Determination of the Proportions of Racial Disparities in HDP Contributed by Neighborhood Environmental Factors Including O3 Exposure, Neighborhood SES, urbanity, and Racial Residential Segregation
Limitations:
Future directions:
Supervisory Committee:
Former Research Mentor: Xiaohui Xu, PhD, MD, Department of Epidemiology & Biostatistics, TAMU
Academic Advisors:
Florida Department of Health
All faculty, staff, and fellow students in the Department of Epidemiology