ADI is a widely used measure of socioeconomic disadvantage at various geographical levels [2729]. We took the following steps to calculate the ADI using the latest Census data: (1) we used 71 independent census variables from 5-year estimate American Community Survey data of 2018 to construct 17 ADI grouped variables, and these census variables include: education (such as the percentage of population aged ≥25 y with at least a high school diploma), income (such as median family income), housing condition (such as percentage of owner-occupied housing units) and employment (such as percentage of employed persons aged ≥16 y in white-collar occupations); (2) we summed up weighted 17 ADI components as total scores using Singh et al. methodology [29]; and, (3) we normalized total scores to have a mean of 100 and a standard deviation of 20. We constructed the ADI raw scores for 52 states (i.e., continental states, Alaska, Hawaii, and Puerto Rico) at the county level and assigned each county to one of four equally-sized ADI levels based on its ADI score (the highest/Q4: 76th–100th percentile of the ADI score, high/Q3: 51st to 75th percentile, low/Q2: 26th to 50th percentile, and the lowest/Q1: 1st to 25th percentile). The higher the ADI, the higher level of disadvantage in a county.

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