Non-urban Counties Research Articles

Criminal legal system engagement among people who use drugs in Oregon following decriminalization of drug possession

BackgroundIn February 2021, Measure 110 (M110) in Oregon decriminalized noncommercial possession of drugs. We examined criminal legal system (CLS) involvement of people who use drugs (PWUD) 2 years after decriminalization. MethodsWe conducted a quantitative survey of PWUD (N=468) in eight Oregon counties between March and November 2023. We ran multivariable models to examine predictors of CLS involvement and law enforcement stops. ResultsThe majority of PWUD (74 %) reported any past year CLS involvement; 67 % had at least one law enforcement stop (mean of 11.4 and median of 3 law enforcement stops) and 33 % had at least one jail incarceration. Among PWUD whom law enforcement had found to possess drugs (n=101), 77 % had their drugs seized at least once, and 63 % (n=56) were taken into custody for charges that did not include drug use or possession at least once. Younger age, cisgender male identity, unstable housing, and nonurban county location were associated with a higher prevalence of any CLS involvement. PWUD who were unstably housed had 6.80 more law enforcement stops than housed PWUD (95 % CI: 4.03–9.57). PWUD in nonurban counties experienced 9.73 more law enforcement stops than those in urban areas (95 % CI: 4.90–14.56). No significant differences were found by race or ethnicity and CLS involvement. Only 13 % of PWUD were aware that all drugs had been decriminalized. ConclusionsDespite drug decriminalization, the majority of PWUD in our study reported significant CLS engagement and limited M110 knowledge.

Law enforcement and syringe services program implementation in rural counties in Kentucky: a qualitative exploration

BackgroundExisting research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality.ObjectiveThis study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties.MethodsFrom August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement.ResultsParticipants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries.ConclusionsThe results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity.

Rural–Urban Residence and Maternal Hepatitis C Infection, U.S.: 2010–2018

The prevalence of hepatitis C virus infection among women delivering live births in the U.S. may be higher in rural areas where county-level estimates may be unreliable. The aim of this study is to model county-level maternal hepatitis C virus infection among deliveries in the U.S. In 2020, U.S. natality files (2010-2018) with county-level maternal residence information were used from states that had adopted the 2003 revised U.S. birth certificate, which included a field for hepatitis C virus infection present during pregnancy. Hierarchical Bayesian spatial models with spatiotemporal random effects were applied to produce stable annual county-level estimates of maternal hepatitis C virus infection for years when all states had adopted the revised birth certificate (2016-2018). Models included a 6-Level Urban-Rural County Classification Scheme along with the birth year and county-specific covariates to improve posterior predictions. Among approximately 32 million live births, the overall prevalence of maternal hepatitis C virus infection was 3.5 per 1,000 births (increased from 2.0 in 2010 to 5.0 in 2018). During 2016-2018, posterior predicted median county-level maternal hepatitis C virus infection rates showed that nonurban counties had 3.5-3.8 times higher rates of hepatitis C virus than large central metropolitan counties. The counties in the top 10th percentile for maternal hepatitis C virus rates in 2018 were generally located in Appalachia, in Northern New England, along the northern border in the Upper Midwest, and in New Mexico. Further implementation of community-level interventions that are effective in reducing maternal hepatitis C virus infection and its subsequent morbidity may help to reduce geographic and rural disparities.

Understanding the place of punishment: Disadvantage, politics, and the geography of imprisonment in 21st century America

AbstractStudies suggest that the spatial distribution of punishment in the United States is shifting. This article analyzes variation in prison admissions across U.S. counties to deepen our understanding of the contemporary geography of punishment. While research on punishment generally treats economic and political theories of punishment as distinct, we draw on recent studies of penal attitudes to develop a theoretical argument regarding their possible interconnection. We then use Hierarchical Linear Modeling to test the hypothesis that conservatism, race, and disadvantage are associated with the use of prison and that these factors help to explain why prison admission rates are higher in rural and suburban counties than in urban ones, despite notably higher crime rates in the latter. The results indicate that nonurban counties send more people to prison than urban counties and that socioeconomic disadvantage, the size of the Black population, and conservatism are significant predictors of prison admissions after controlling for crime‐related problems. These findings suggest that poverty, race, and politics work in concert to shape the distribution of punishment across 21st century America.

Social determinants of COVID-19 mortality at the county level.

As of August 2020, the United States is the global epicenter of the COVID-19 pandemic. Emerging data suggests that "essential" workers, who are disproportionately more likely to be racial/ethnic minorities and immigrants, bear a disproportionate degree of risk. We used publicly available data to build a series of spatial autoregressive models assessing county level associations between COVID-19 mortality and (1) percentage of individuals engaged in farm work, (2) percentage of households without a fluent, adult English-speaker, (3) percentage of uninsured individuals under the age of 65, and (4) percentage of individuals living at or below the federal poverty line. We further adjusted these models for total population, population density, and number of days since the first reported case in a given county. We found that across all counties that had reported a case of COVID-19 as of July 12, 2020 (n = 3024), a higher percentage of farmworkers, a higher percentage of residents living in poverty, higher density, higher population, and a higher percentage of residents over the age of 65 were all independently and significantly associated with a higher number of deaths in a county. In urban counties (n = 115), a higher percentage of farmworkers, higher density, and larger population were all associated with a higher number of deaths, while lower rates of insurance coverage in a county was independently associated with fewer deaths. In non-urban counties (n = 2909), these same patterns held true, with higher percentages of residents living in poverty and senior residents also significantly associated with more deaths. Taken together, our findings suggest that farm workers may face unique risks of contracting and dying from COVID-19, and that these risks are independent of poverty, insurance, or linguistic accessibility of COVID-19 health campaigns.

The Emerging Intersection Between Injection Drug Use and Early Syphilis in Nonurban Areas of Missouri, 2012-2018.

The national rate of syphilis has increased among persons who inject drugs (PWID). Missouri is no exception, with increases in early syphilis (ES), congenital syphilis, and PWID, especially in nonurban counties. Disease intervention specialist records for ES cases in Missouri (2012-2018) were examined. Drug use was classified as injection drug use (IDU) (opioid or methamphetamine) or non-IDU (opioid, methamphetamine, or cocaine). Rates were compared based on residence, sex of sex partner, and drug use. Rates of ES in Missouri increased 365%, particularly in small metropolitan and rural areas (1170%). Nonurban areas reported a higher percentage of persons with ES who used injection drugs (12%-15%) compared with urban regions (2%-5%). From 2012 to 2018, women comprised an increasing number of ES cases (8.3%-21%); 93% of women were of childbearing age. Increasingly more women in rural areas with ES also reported IDU during this time (8.4%-21.1%). As syphilis increases in small metropolitan and rural regions, access to high-quality and outreach-based sexual health services is imperative. Healthcare policy to equip health departments with harm reduction services and drug treatment resources offers an opportunity to impact both syphilis increases as well as health outcomes associated with IDU.

Unsupervised learning for county-level typological classification for COVID-19 research

The analysis of county-level COVID-19 pandemic data faces computational and analytic challenges, particularly when considering the heterogeneity of data sources with variation in geographic, demographic, and socioeconomic factors between counties. This study presents a method to join relevant data from different sources to investigate underlying typological effects and disparities across typologies. Both consistencies within and variations between urban and non-urban counties are demonstrated. When different county types were stratified by age group distribution, this method identifies significant community mobility differences occurring before, during, and after the shutdown. Counties with a larger proportion of young adults (age 20–24) have higher baseline mobility and had the least mobility reduction during the lockdown.

Magnitude and Chronicity of Environmental Smoke Exposure Across Infancy and Early Childhood in a Sample of Low-Income Children.

Infants and young children may be at an increased risk for second- and thirdhand exposure to tobacco smoke because of increased respiration rate and exposure to surface residue. However, relatively fewer studies have examined biomarkers of exposure (cotinine) in children under age 4 years. This study examines the magnitude and chronicity of exposure across early childhood among children from low-income families in order to better characterize contextual risk factors associated with exposure. A total of 1292 families were recruited in six nonurban counties of Pennsylvania and North Carolina. Cotinine was assayed from infant saliva at 6, 15, 24, and 48 months of age (N = 1218), and categorized as low (≤0.45 ng/mL), moderate (0.46-12 ng/mL), or high (≥12 ng/mL) at each time point. Categories were highly correlated across time. Latent class analysis was used to summarize patterns of exposure categories across time. Magnitude of exposure in this sample was high, with approximately 12% of infants registering cotinine values at least 12 ng/mL, consistent with active smoking in adults. Greater exposure was associated with lower income, less education, more residential instability, and more instability in adult occupants in the home, whereas time spent in center-based day care was associated with lower exposure. Young children from low-income, nonurban communities appear to bear a higher burden of secondhand smoke exposure than previous studies have reported. Results contribute to understanding populations at greater risk, as well as specific, potentially malleable, environmental factors that may be examined as direct contributors to exposure. Results suggest that infants from low-income, nonurban families have higher risk for environmental smoke exposure than data from nationally representative samples. Predictors of exposure offer insights into specific factors that may be targeted for risk reduction efforts, specifically conditions of children's physical space. In addition to considering the increases in risk when an adult smoker lives in a child's home, families should also attend to the possible risk embedded within the home itself, such as residual smoke from previous occupants. For high-risk children, day care appears to mitigate the magnitude of exposure by providing extended time in a smoke-free environment.

Socioeconomic Risk and School Readiness: Longitudinal Mediation Through Children's Social Competence and Executive Function.

The association of socioeconomic status with academic readiness and school achievement is well established. However, the specific contributions of cognitive and social aspects of self-regulation, and potential reciprocal relations between them in the prediction of school readiness and early school achievement have not previously been examined. This study examined mediational processes involving children's executive function (EF) skills at 58 months and Grade 1 (G1) and social competence in Kindergarten (K) and G1, as potential pathways by which early-life poverty-related risks influence Grade 2 (G2) math and reading achievement. Data came from the Family Life Project, which is a prospective longitudinal study of 1,292 children and families followed from birth in primarily low-income, non-urban counties in Pennsylvania (PA) and North Carolina (NC). Autoregressive cross-lagged mediation analyses indicated that EF at 58 months through EF at G1 mediated negative associations between cumulative risk exposure and academic skills, with this pathway mediating 36% of the total effect. Furthermore, social competence at K through EF at G1 mediated negative associations between early-life cumulative socioeconomic risk and academic skills, mediating 16% of the total effect. These findings provide evidence that poverty-related risks can influence school readiness and academic achievement via EF. Additionally, these results provide preliminary support for the premise that social competence through EF is a pathway by which cumulative poverty-related risk predicts early academic competence. Our findings are consistent with studies demonstrating developmental associations between EF and social competence. Furthermore, our findings are consistent with prekindergarten programs for children in poverty that emphasize both cognitive and social aspects of self-regulation.

Wind electricity subsidies — A windfall for landowners? Evidence from a feed-in tariff in Germany

Subsidies for renewable energy sources are increasing around the globe and amounted to more than 100 billion euro in 2013. This study aims to answer whether the subsidies only ensure that green electricity plants are profitable or whether other market participant – as, for example, landowners – benefit from the subsidy in the form of windfall gains as well. To identify the causal effect of the subsidies, we investigate the impact of the introduction of a price guarantee in the form of a feed-in tariff for wind electricity in Germany on land prices. We employ two different approaches. Both approaches exploit quasi-experimental variation in wind strength across 260 non-urban counties in combination with the introduction of the subsidies. Based on a difference-in-differences design, we find that land prices increased by roughly 1100 euro in high-wind areas after the introduction of the subsidy. Further, using an instrumental variable estimator we document that around 18% of expected wind turbine profits are capitalized into land prices. Finally, we show that wind turbine subsidies account for 4% of overall agricultural income in 2007.

Urban and non-urban differences in community living and participation among individuals with serious mental illnesses

Despite a wealth of studies examining the relationship between urbanicity (i.e., living in an urban area) and psychological distress, there is a paucity of research examining the relationship between urbanicity, community living, and community participation of adults with serious mental illnesses. This study addresses this knowledge gap by assessing urban and non-urban differences in community participation, sense of community, mental health stigma, and perceptions of the neighborhood environment among individuals with serious mental illnesses living independently throughout the United States. A total of 300 individuals with serious mental illnesses recruited from 21 outpatient mental health service organizations in 15 states completed a phone survey about their community living and participation experiences. Urbanicity was examined at two spatial scales (block group and county), and independent-samples t-tests were employed to assess urban and non-urban differences in community living and participation variables. Levels of community participation and perceptions of neighborhood quality and crime were higher in urban block groups; sense of community was higher in urban counties; and perceptions of mental health stigma were higher in non-urban counties. Results inform the methodological literature on best practices for assessing urbanicity, as well as interventions aimed at increasing community participation and improving aspects of the built and social environment that affect individuals who experience mental health distress.

Foreclosure, Inequality, and the Difference That Place Makes

AbstractWhile the Great Recession and the associated rise in foreclosures significantly impacted households across the United States, default rates in rural areas and rural‐urban foreclosure differences have failed to attract substantial research attention. To expand the scale and scope of the foreclosure literature, this article examines place‐based differences in estimated foreclosure rates across U.S. counties, which are classified as urban, suburban, micropolitan, or rural. Defaults are considered both overall and for each county classification, and are related to income distribution and inequality, homeownership, adjudication of default, place‐based factors including amenity scores and proximity to urban areas, and geographic region. The article finds a complex relationship among these variables, with inequality itself negatively associated with default rates and lower‐middle−income households positively related to foreclosure. Further, while proximity to urban areas is positively related to foreclosure rates among nonurban counties, natural amenities are related to lower default rates in these areas. The article concludes by considering policy implications, and recommends expanding foreclosure mitigation and prevention strategies to nonurban places.

Criminal Justice System Should Be Delinked From MH System, Says Expert

Back to table of contents Previous article Next article Government NewsFull AccessCriminal Justice System Should Be Delinked From MH System, Says ExpertAaron LevinAaron LevinSearch for more papers by this authorPublished Online:1 Dec 2016https://doi.org/10.1176/appi.pn.2016.12a6AbstractPrisoners are sicker in every way—including psychiatrically—than people on the outside.“Why do we use the criminal justice system rather than other social institutions like the health system to deal with mental illness and substance abuse?” asks sociologist R. Hugh Potter, Ph.D., a professor and director of research in the Department of Criminal Justice and Legal Studies at the University of Central Florida in Orlando.Sociologist R. Hugh Potter, Ph.D., says that new leadership is needed that appreciates non-criminal justice agencies—ones concerned with health, mental illness, and social well-being.Abigail BellPeople with purely criminal behavior and no mental illness should indeed fall into the domain of the criminal justice system, where evidence-based interventions can address their criminogenic risk factors: prior criminal history, antisocial behavior, family instability, unemployment, poor social skills, anger, and substance abuse.“But people whose criminality is due only to their possession of drugs or having a mental illness probably shouldn’t be dealt with in jails and prisons,” said Potter at a conference on “Ethical Challenges in Correctional Mental Health Care” in Philadelphia in October.The conference was sponsored by the Thomas Scattergood Behavioral Health Foundation, the Leonard Davis Institute at the University of Pennsylvania, and the Lindy Institute for Urban Innovation at Drexel University.Potter also sees structural problems.“Most police departments are small, but they are larger than the local health department,” he said. “So where do you turn to handle a crisis? Probably law enforcement.”Inevitably, police take the individual to the local jail, especially if no mental health facility is available.“We complain about the criminal justice system, but who will respond if we take it out of the mix?” he said. “Most nonurban counties don’t even have a psychiatrist.”Creating alternatives is not easy. About 3,000 police departments, including most larger ones, have received Crisis Intervention Training (CIT) to help officers manage people with suspected mental illness. However, that leaves another 12,000 departments, mostly small ones, without CIT training. Yet another crisis awaits at the cell door. Overall, people in jails and prisons are sicker, have more mental illness, and are more disabled that those on the outside.Bureau of Justice Statistics figures show higher rates of self-reported illness in correctional populations compared with the general population, with the rate of mental illnesses four to five times higher than that found outside the walls, said Potter.About 40 percent of jail inmates and 30 percent of prisoners report at least one disability, and women have even higher rates. Mentally ill prisoners also report higher rates of victimization by staff and other prisoners.And that’s not the full picture, said Potter. Only 7 percent of people booked into jails end up in prison, and 70 percent of those charged with felonies spend no more than 48 hours in jail.“So the people who stay in jail are homeless, mentally ill, or disabled or don’t have the money for bail,” he said. There are no good statistics on what happens to the 6 million people a year who are released. No one knows how many might have a mental illness or if they get any treatment.If the resort to law enforcement to manage people with mental illness seems undesirable, Potter asked, then who will respond, how will due process be guaranteed, and who will pay for any intervention? To Potter, the starting point lies in separating criminogenic risk from mental health issues.“We need a workforce that is cross-trained in mental health interventions and constitutional rights, not one or the other, and not in opposition to each other,” he said. “We need real attention on communities rather than formal governmental institutions.” ■ ISSUES NewArchived

Airborne Fine Particles and Risk of Hospital Admissions for Understudied Populations: Effects by Urbanicity and Short-Term Cumulative Exposures in 708 U.S. Counties.

Background:Evidence of health risks associated with ambient airborne fine particles in nonurban populations is extremely limited.Objective:We estimated the risk of hospitalization associated with short-term exposures to particulate matter with an aerodynamic diameter < 2.5 μm (PM2.5) in urban and nonurban counties with population ≥ 50,000.Methods:We utilized a database of daily cardiovascular- and respiratory-related hospitalization rates constructed from Medicare National Claims History files (2002–2006), including 28 million Medicare beneficiaries in 708 counties. Daily PM2.5 exposures were estimated using the Community Multiscale Air Quality (CMAQ) downscaler. We used time-series analysis of hospitalization rates and PM2.5 to evaluate associations between PM2.5 levels and hospitalization risk in single-pollutant models.Results:We observed an association between cardiovascular hospitalizations and same-day PM2.5 with higher risk in urban counties: 0.35% [95% posterior interval (PI): –0.71%, 1.41%] and 0.98% (95% PI: 0.73%, 1.23%) increases in hospitalization risk per 10-μg/m3 increment in PM2.5 were observed in the least-urban and most-urban counties, respectively. The largest association for respiratory hospitalizations, a 2.57% (95% PI: 0.87%, 4.30%) increase per 10-μg/m3 increase in PM2.5, was observed in the least-urban counties; in the most-urban counties, a 1.13% (0.73%, 1.54%) increase was observed. Effect estimates for cardiovascular hospitalizations were highest for smaller lag times, whereas effect estimates for respiratory hospitalizations increased as more days of exposure were included.Conclusion:In nonurban counties with population ≥ 50,000, exposure to PM2.5 is associated with increased risk for respiratory hospitalizations; in urban counties, exposure is associated with increased risk of cardiovascular hospitalizations. Effect estimates based on a single day of exposure may underestimate true effects for respiratory hospitalizations.Citation:Bravo MA, Ebisu K, Dominici F, Wang Y, Peng RD, Bell ML. 2017. Airborne fine particles and risk of hospital admissions for understudied populations: effects by urbanicity and short-term cumulative exposures in 708 U.S. counties. Environ Health Perspect 125:594–601; http://dx.doi.org/10.1289/EHP257

Heat-Related Mortality In Urban And Non-Urban Counties Of China

Introduction: Few multi-location studies of heat-related mortality have been conducted in developing countries, especially China. Moreover, the vast majority of previous multi-location studies only focused on urban areas; little is known of the health effect of high temperature in non-urban areas. This study explored the heat-related mortality risk in 102 urban and non-urban counties in one province, China. Methods: A distributed lag non-linear model was first applied to evaluate the heat-mortality relationship in 102 counties during 2009 to 2013. Then, a Bayesian hierarchical model was used to pool the estimates across all counties. Effect modification by individual characteristics such as sex, age, and education were also examined by stratified analysis. Finally, county-level characteristics such as percentage of urban population and air conditioning were analyzed to explain the variation in heat-related mortality risks by county. Results: The overall cumulative relative risk at the 99th vs. 75th percentiles (32.47°C vs. 24.23°C) in 102 counties was 1.35(95%CI, 1.30-1.39) for total mortality and 1.56(95%CI, 1.49-1.64) for cardiorespiratory mortality. The heat effects on cardiorespiratory and total mortality were both stronger in non-urban counties than those in urban counties. Female, elderly people, and people with low educational level were found to be more vulnerable. County characteristics such as percentage of urban population, education, and air conditioning were all significantly associated with decreased risk estimates, while percentage of elderly people(≥ 65 years old) was significantly associated with increased risk estimates. Conclusions: Our findings reveal that non-urban areas in China have significantly high heat-related mortality risks. This evidence has important implications for adaptation planning in Chinese rural areas under a changing climate.

Chemical Composition of Fine Particulate Matter and Life Expectancy: In 95 US Counties Between 2002 and 2007.

In a previous study, we provided evidence that a decline in fine particulate matter (PM2.5) air pollution during the period between 2000 and 2007 was associated with increased life expectancy in 545 counties in the United States. In this article, we investigated which chemical constituents of PM2.5 were the main drivers of the observed association. We estimated associations between temporal changes in seven major components of PM2.5 (ammonium, sulfate, nitrate, elemental carbon matter, organic carbon matter, sodium, and silicon) and temporal changes in life expectancy in 95 counties between 2002 and 2007. We included US counties that had adequate chemical components of PM2.5 mass data across all seasons. We fitted single pollutant and multiple pollutant linear models, controlling for available socioeconomic, demographic, and smoking variables and stratifying by urban and nonurban counties. In multiple pollutant models, we found that: (1) a reduction in sulfate was associated with an increase in life expectancy; and (2) reductions in ammonium and sodium ion were associated with increases in life expectancy in nonurban counties only. Our findings suggest that recent reductions in long-term exposure to sulfate, ammonium, and sodium ion between 2002 and 2007 are associated with improved public health.

School Start Time and Adolescent Sleep Patterns: Results From the U.S. National Comorbidity Survey--Adolescent Supplement.

We estimated associations between school start time and adolescent weeknight bedtime, weeknight sleep duration, and weekend compensatory sleep and assessed whether associations differ by age, sex, or urbanicity. We used a subsample of a nationally representative, cross-sectional survey of 7308 students aged 13 to 18 years attending 245 schools to estimate associations of school start time, reported by school principals, with weeknight bedtime and sleep duration and weekend compensatory sleep, reported during adolescent face-to-face interviews. Start time was positively associated with weeknight bedtime. Associations between start time and weeknight sleep duration were nonlinear and were strongest for start times of 8:00 am and earlier. Associations differed by sex and urbanicity, with the strongest association among boys in major metropolitan counties. Start time was negatively associated with sleep duration among boys in nonurban counties. Start time was not associated with weekend compensatory sleep. Positive overall associations between school start time and adolescent sleep duration at the national level support recent policy recommendations for delaying school start times. However, the impact of start time delays may differ by sex and urbanicity.

Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012.

Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the US epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). We examined trends in incidence of acute hepatitis C among young persons reported to the Centers for Disease Control and Prevention (CDC) during 2006-2012 by state, county, and urbanicity. Sociodemographic and behavioral characteristics of HCV-infected young persons newly reported from 2011 to 2012 were analyzed from case interviews and provider follow-up at 6 jurisdictions. From 2006 to 2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in nonurban counties (P = .003) vs 5% annually in urban counties (P = .028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in nonurban counties east of the Mississippi River. Of 1202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. These data indicate an emerging US epidemic of HCV infection among young nonurban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in nonurban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention.

Connecting race and place: a county-level analysis of White, Black, and Hispanic HIV prevalence, poverty, and level of urbanization.

We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black-White and Hispanic-White prevalence rate ratios (PRRs) across levels of urbanization and poverty. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black-White and Hispanic-White PRRs were not statistically different from 1.0 at high poverty rates (Black-White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic-White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.

Antibiotic Resistance in Non–Major Metropolitan Skilled Nursing Facilities: Prevalence and Interfacility Variation

Antibiotic Resistance in Non–Major Metropolitan Skilled Nursing Facilities: Prevalence and Interfacility Variation