Nonmetropolitan Counties Research Articles

Urban Classification, Not COVID-19 Community Rates, Was Associated With Modes of Learning in US K-12 Schools?

To identify factors associated with the decision to provide in-person, hybrid, and remote learning in kindergarten through 12th grade school districts during the 2020-2021 school year. We performed a retrospective study evaluating school district mode of learning and community coronavirus 2019 (COVID-19) incidence and percentage positivity rates at 3 time points during the pandemic: (1) September 15, 2020 (the beginning of the school year, before Centers for Disease Control and Prevention guidance); (2) November 15, 2020 (midsemester after the release of Centers for Disease Control and Prevention guidance and an increase of COVID-19 cases); and (3) January 15, 2021 (start of the second semester and peak COVID-19 rates). Five states were included in the analysis: Michigan, Missouri, North Carolina, Ohio, and Wisconsin. The primary outcome was mode of learning in elementary, middle, and high schools during 3 time points. The measures included community COVID-19 incidence and percentage positivity rates, school and student demographics, and county size classification of school location. No relationship between mode of learning and community COVID-19 rates was observed. County urban classification of school location was associated with mode of learning with school districts in nonmetropolitan and small metropolitan counties more likely to be in-person. Community COVID-19 rates did not appear to influence the decision of when to provide in-person learning. Further understanding of factors driving the decisions to bring children back into the classroom are needed. Standardizing policies on how schools apply national guidance to local decision-making may decrease disparities in emergent crises.

Exploring spatial variations of US rock music concerts in relation to population demographics and leisure and hospitality industry

ABSTRACT Rock music is an integral part of American culture. This paper presents a study of sensing and analysing over 57,000 rock music live performances between 2007 and 2017. Spatial traces of 575 rock music artists performing in concerts nationwide were collected from a major music streaming platform Spotify. Location-based concert data were analysed to explore economic and geographic factors linked to the landscape of rock music live performance and to reveal the importance of population demographics and leisure and hospitality (LH) economics to the culture and music industries from a spatial aspect. Over 90% of rock concerts between 2007 and 2017 were found in 250 counties. The aim of the study is to specify and develop a model that reasonably accounts for spatial heterogeneity present in the concert data. By regressing rock concert data against demographic data and LH establishment data, ordinary least squares (OLS) models were better fitted in metropolitan counties than non-metropolitan counties. Spatial dynamics of concerts were revealed by local R2 values and the obtained structure in the form of spatial heterogeneity was then explained using geographically weighted regression (GWR) models. High population density and LH services in industry-leading cities such as New York City, Los Angeles, Chicago and Houston exhibit advantages in explaining rock concert distributions. Findings from the models reflect the live music industry’s interrelationships to the LH industry and suggest LH services being essential considerations in selecting concert destinations for rock musicians.

Structural modeling of COVID-19 spread in relation to human mobility

Human mobility is considered as one of the prominent non-pharmaceutical interventions to control the spread of the pandemic (positive effect from mobility to infection). Conversely, the spread of the pandemic triggered massive changes to people’s daily schedules by limiting their movement (negative effect from infection to mobility). The purpose of this study is to investigate this bi-directional relationship between human mobility and COVID-19 spread across U.S. counties during the early phase of the pandemic when infection rates were stabilizing and activity-travel behavior reflected a fairly steady return to normal following the drastic changes observed during the pandemic’s initial shock. In particular, we applied Structural Regression (SR) model to investigate a bi-directional relationship between COVID-19 infection rate and the degree of human mobility in a county in association with socio-demographic and location characteristics of that county, and state-wide COVID-19 policies. Combining U.S. county-level cross-sectional data from multiple sources, our model results suggested that during the study period, human mobility and infection rate in a county both influenced each other, but in an opposite direction. Metropolitan counties experienced higher infection and lower mobility than non-metropolitan counties in the early stage of the pandemic. Counties with highly infected neighboring counties and more external trips had a higher infection rate. During the study period, community mitigation strategies, such as stay at home order, emergency declaration, and non-essential business closure significantly reduced mobility whereas public mask mandate significantly reduced infection rates. The findings of this study will provide important insights to policy makers in understanding the two-way relationship between human mobility and COVID-19 spread and to derive mobility-driven policy actions accordingly.

Elevated serious psychological distress, economic disruption, and the COVID-19 pandemic in the nonmetropolitan American West

In this study we examined the psychological distress, self-rated health, COVID-19 exposure, and economic disruption of a sample of the nonmetropolitan western U.S. population and labor force one year after the start of the COVID-19 pandemic. Using novel primary survey data from non-metropolitan counties in the eleven contiguous western United States collected from February 28 until April 3, 2021 (n = 1203), we descriptively analyzed variables and estimated binomial and multinomial logit models of the association between economic disruption, COVID-19 exposure, self-rated health, and psychological distress. Results showed there was widespread presence of psychological distress, COVID-19 exposure, and economic disruption among the overall sample and members of the labor force. There was extremely high incidence of serious psychological distress (14.8% CI [12.1,17.8] of the weighted sample), which was heightened among the labor force (16.6%, CI [13.0,20.9] of those in the labor force). We found economic disruption was associated with severe psychological distress, but exposure to infection was not. Comparatively, overall self-rated health was at similar levels as prior research and was not significantly associated with economic disruption or COVID-19 exposure. COVID-19, particularly its associated economic effects, had a significant relationship with serious psychological distress in this sample of adults in the nonmetropolitan western United States.

Who benefits from Renewable Electricity? The differential effect of wind power development on rural counties in the United States

Wind power development has rapidly expanded in rural areas in the United States. It is widely accepted that there are positive economic impacts of wind power projects, but less clear is whether those benefits are the same in rural areas as compared to more metropolitan locations. This paper examines this question using two complimentary approaches. It first examines the impacts of increases in accumulated wind power capacity across all U.S. counties with wind power from 1990 to 2015 to establish a baseline for counties regardless of their urbanity. To measure the economic and demographic impacts of wind development in rural counties, we compare rural (nonmetropolitan and nonurban) counties with wind developments over 100 megawatts to a group of similar rural counties lacking wind developments. We find that wind power has significant positive effects on per capita income, farm income, employment, and reduced poverty rates when considering all counties. However, for rural counties, the only statistically significant effect is on farm income, which may well stem from land lease payments. We surmise that rural areas do not fully capitalize on the economic benefits of wind power development because of their small and often highly specialized economies.

Social isolation, residential stability, and opioid use disorder among older Medicare beneficiaries: Metropolitan and non-metropolitan county comparison

Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as society ages, but this issue receives the least attention in the literature. To address this gap, this study utilizes county-level data from multiple data sources (1) to investigate whether social isolation is associated with OUD prevalence among older Medicare beneficiaries, (2) to examine whether and how residential stability moderates the association between social isolation and OUD prevalence in US counties, and (3) to determine if there are any differences in these associations between metropolitan and non-metropolitan counties. The results show that social isolation is a significant factor for county-level OUD prevalence, regardless of metropolitan status. In addition, counties with high residential stability have low prevalence of OUD among older adults and this association is stronger in metropolitan than in non-metropolitan counties. Nonetheless, high levels of residential stability reinforce the positive relationship between social isolation and OUD prevalence. As a result, when developing policies and interventions aimed at reducing OUD among older adults, place of residence must be taken into account.

The neglected ones: Time at home during COVID-19 and child maltreatment

The early months of the COVID-19 pandemic led to extreme social isolation, precarious employment and job loss, working from home while tending to children, and limited access to public services. The confluence of these factors likely affects child health and well-being. We combine early release child maltreatment reports in Indiana with unique and newly available mobile phone movement data to better understand the relationship between staying at home intensively during the COVID-19 pandemic and child maltreatment. Our findings indicate that the prolonged stays at home promoted by the early public health response to COVID-19 resulted in reductions in child maltreatment reports overall and substantiated reports of maltreatment. However, relative to areas that stayed home less, children in areas that stayed home more were more likely to be both reported for and a confirmed victim of maltreatment, particularly neglect. These areas have historically been socioeconomically advantaged and experienced lower rates of maltreatment. We only observe increases in confirmed child maltreatment in metropolitan counties, suggesting that the effects of staying home on child maltreatment may reflect both the differential risk of leaving home and access to services in metropolitan–rather than non-metropolitan–counties. Staying at home has been challenging for many families. Families likely need assistance as the pandemic persists, evolves, and when it ends.

QuickStats: Infant Mortality Rates for Metropolitan and Nonmetropolitan Counties,* by Single Race and Hispanic Origin - National Vital Statistics System, United States, 2019.

QuickStats: Infant Mortality Rates for Metropolitan and Nonmetropolitan Counties,* by Single Race and Hispanic Origin - National Vital Statistics System, United States, 2019.

Racial and ethnic differences in COVID-19 hospitalizations by metropolitan status among Medicare beneficiaries, 1 January-31 December 2020.

Risk for COVID-19 hospitalizations increases with increasing age and presence of underlying medical conditions. However, the burden has not been well-assessed in metropolitan and nonmetropolitan areas by race/ethnicity among Medicare population with chronic conditions. We used the 2020 Medicare data to estimate COVID-19 hospitalization rates by race/ethnicity among Medicare beneficiaries for COVID-19 by metropolitan status and to assess the association of hospitalizations from COVID-19 with each of selected 29 chronic conditions for patients by metropolitan status and by race/ethnicity. The COVID-19 hospitalization rate was higher among beneficiaries residing in nonmetropolitan counties than those residing in metropolitan counties in 2020. Approximately 1 in 2 AI/AN, 1 in 3 NHB, Hispanic and A/PI, and 1 in 4 NHW beneficiaries with COVID-19 residing in nonmetropolitan counties were hospitalized. Beneficiaries with COVID-19 and chronic conditions were more likely to be hospitalized compared with those without chronic conditions. Hospitalization rates among beneficiaries with COVID-19 and chronic conditions were not distributed equally by race/ethnicity and by metropolitan status. Researchers, policymakers and practitioners can use these findings to explore more effective ways of reducing racial/ethnic and geographic disparities among minorities disproportionately affected by COVID-19 and are at highest risk of hospitalization.

Effect of farm structure on rural community well-being

The current crisis in US agriculture has seen a growing number of farm bankruptcies. The result has been a “hollowing out” of the middle in the distribution of farm size, with growth in the number of both very large and small farms. A growing number of farms are operated by part-time farmers whose primary occupation is no longer farming. What are some implications of these changes for the well-being of rural communities? Using U.S. non-metropolitan (rural) county level data, we explore how the changing nature of farming has affected community well-being as understood through seven diverse measures. In general, we find conflicting evidence on the impact of farm structure on community well-being. In the end our results suggest that the logical conclusion of what has become known as the Goldschmidt hypothesis line of thinking that the movement to fewer and larger farms will necessarily harm the well-being of the larger community is not supported by the data.

Disparities in Cancer Screening: The Role of County-Level Metropolitan Status and Racial Residential Segregation

Mortality from cervical and colorectal cancers can be reduced through routine screening, which can often be accessed through primary care. However, uptake of screening in the US remains suboptimal, with disparities observed across geographic characteristics, such as metropolitan status or level of racial residential segregation. Little is known about the interaction of metropolitan status and segregation in their relationship with cancer screening. We conducted a quantitative survey of 474 women aged 45-65 in central Pennsylvania. The survey collected county-level characteristics and participant-level demographics, beliefs, cancer screening barriers, and cervical and colorectal cancer screening. We used bivariate and multivariable logistic regression to analyze relationships between metropolitan status and segregation with screening. For cervical cancer screening, 82.8% of participants were up-to-date, which did not differ by county type in the final analysis. Higher healthcare trust, higher cancer fatalism, and reporting cost as a barrier were associated with cervical cancer screening. For colorectal cancer screening, 55.4% of participants were up-to-date, which differed by county type. In metropolitan counties, segregation was not associated with colorectal cancer screening, but in non-metropolitan counties, segregation was associated with greater colorectal cancer screening. The relationship between metropolitan status and being up-to-date with colorectal, but not cervical, cancer screening varied by segregation. Other important beliefs and barriers to screening varied by county type. This research can guide future cancer screening interventions in primary care settings in underserved communities.

County-level characteristics associated with incidence, late-stage incidence, and mortality from screenable cancers

BackgroundCancer screening differs by rurality and racial residential segregation, but the relationship between these county-level characteristics is understudied. Understanding this relationship and its implications for cancer outcomes could inform interventions to decrease cancer disparities. MethodsWe linked county-level information from national data sources: 2008–2012 cancer incidence, late-stage incidence, and mortality rates (for breast, cervical, and colorectal cancer) from U.S. Cancer Statistics and the National Death Index; metropolitan status from U.S. Department of Agriculture; residential segregation derived from American Community Survey; and prevalence of cancer screening from National Cancer Institute’s Small Area Estimates. We used multivariable, sparse Poisson generalized linear mixed models to assess cancer incidence, late-stage incidence, and mortality rates by county-level characteristics, controlling for density of physicians and median household income. ResultsCancer incidence, late-stage incidence, and mortality rates were 6–18% lower in metropolitan counties for breast and colorectal cancer, and 2–4% lower in more segregated counties for breast and colorectal cancer. Generally, reductions in cancer associated with residential segregation were limited to non-metropolitan counties. Cancer incidence, late-stage incidence, and mortality rates were associated with screening, with rates for corresponding cancers that were 2–9% higher in areas with more breast and colorectal screening, but 2–15% lower in areas with more cervical screening. DiscussionLower cancer burden was observed in counties that were metropolitan and more segregated. Effect modification was observed by metropolitan status and county-level residential segregation, indicating that residential segregation may impact healthcare access differently in different county types. Additional studies are needed to inform interventions to reduce county-level disparities in cancer incidence, late-stage incidence, and mortality.

Association and risk factors of healthcare-associated infection and burden of illness among chemotherapy-induced ulcerative mucositis patients.

ObjectivesTo evaluate the association and risk factors of healthcare-associated infection (HAI) and burden of illness among chemotherapy-induced ulcerative mucositis (UM) patients.MethodsFor this research, US National Inpatient Sample database 2017 was utilized to study UM patients. The association of healthcare-associated infection-related burden of illness among UM patients was assessed on the outcome––length of hospital stays (LOS), total charges, in-hospital mortality, and discharge disposition.ResultIn 2017, there were 11,350 adult (> 18 years of age) UM patients, among them there were 415 (3.5%) HAI. After adjusting for patient and clinical characteristics, UM patients with HAI were most likely to have higher total charges and longer LOS (1.91; 95% CIs: 1.51–2.41; P < 0.001; 1.84; 95% CIs: 1.53–2.21; P < 0.001) than those without HAI. Further, mortality was not significantly different. UM patients with HAI were less likely to have higher burden of illness who were younger, females, those living in non-metropolitan or micropolitan counties, and those with lower co-morbidity score. Additionally, UM patients with HAI were more likely to discharge to skilled nursing facility (SNF), intermediate care facility (ICF), and another type of facility (ATF), (aOR = 2.58 (1.16–5.76), P = 0.02), than they were to discharge to self-care or home care.ConclusionUM patients with HAI were more likely to have higher burden of illness and more likely to discharged to the SNF, ICF, and ATF rather than to home or self-care.Clinical relevanceUM patients when associated with HAI have higher burden of illness; a tailored approach to oral care might prevent HAIs and burden of illness among UM.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00784-021-04106-0.

Trauma center funding: time for an update

BackgroundUncompensated care (UC) is healthcare provided with no payment from the patient or an insurance provider. UC directly contributes to escalating healthcare costs in the USA and potentially impacts patient...

The power of the future: Intergenerational income mobility and child maltreatment in the United States

BackgroundRecent research has shown that the likelihood of children experiencing intergenerational, upward income mobility depends on the community in which they are raised. Whether parents consider their children's economic chances in their parenting decisions, however, is not well understood. ObjectiveTo examine the relationship between county-level income mobility–distinct from income inequality and poverty–and child maltreatment. Participants and settingAdministrative data from the National Child Abuse and Neglect Data System: Child File for 2406 counties were merged with measures of intergenerational income mobility from Chetty et al. (2014a), including the probability that a child born in the bottom quintile of the national income distribution reaches the top quintile by age thirty. MethodsWeighted least squares analyses were used to empirically estimate the relationship between intergenerational income mobility and child maltreatment report rates. Maltreatment reports were also divided into subgroups by age and metropolitan status. ResultsCounties where children have a greater chance of moving up the income ladder have lower child maltreatment report rates, independent from income inequality and poverty rates. This relationship is consistent across all child ages (0–17). The relationship between upward income mobility and substantiated child maltreatment is also negatively correlated among non-metropolitan counties. ConclusionsChildren experience a lower risk for maltreatment if they are more likely to move up the income ladder in adulthood. Macroeconomic factors and policies that reduce income inequality and enhance economic mobility are likely to prevent child maltreatment.

The Urban–Rural Divide: The Effects of the Small Business Innovation Research Program in Small and Nonmetro Counties

This study assesses the efficacy of the Small Business Innovation Research Program on innovation, employment, and business formation in small and nonmetropolitan counties. The primary goal is to further understand rural innovation and growth process through government intervention on small business development. Using panel data and employing fixed-effect models, the results suggest that, compared with large metropolitan counties, the Small Business Innovation Research Program may not be an effective program to generate employment and entrepreneurship opportunities in small and nonmetropolitan regions, but it could be a viable source to improve rural innovation outcome. The geographical effects of the program are heterogeneous across implementation years and award agencies. This study contributes to the innovation policy agenda in small and nonmetropolitan regions, which is an important and emerging topic in the field.

Opportunity and Place: Latino Children and America’s Future

We examine the spatial distribution of Hispanic children and analyze its relationship to the geography of opportunity. We describe the spatial distribution of Hispanic children across all U.S. counties, document their exposure to salutary and deleterious conditions, and compare exposure to these conditions among children living in metropolitan and nonmetropolitan counties that represent traditional and new destinations for immigrants. We find clear evidence of racial and geographic differences in opportunity, at least as defined by spatially uneven patterns of intergenerational mobility. We show that the typical Hispanic child is highly isolated, living in a county with a majority-minority population, high rates of poverty, low levels of education, and poor public health. Opportunities are limited in metropolitan core counties, where the large majority of Hispanic children live, and the movement of immigrant families from traditional gateways to new destinations provides little to children in terms of exposure to more opportunity.

Geographic access to brachytherapy services in the United States

PURPOSEDisparities in geographic access to medical care exist in nearly all fields of medicine including radiation oncology. We aim to update knowledge of the geographic distribution of radiation oncologists in the United States. METHODS AND MATERIALSWe used the Physician and Other Supplier Public Use File (PUF) from the Centers for Medicare & Medicaid Services (CMS) as well as the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) database to identify practices that either coded for or are marked as having access to brachytherapy services. Geographic analysis was performed on several levels including United States (US) Census region, Dartmouth Atlas Healthcare Referral Region, and the county level. RESULTSWe identified 327 providers that billed for a brachytherapy code during the calendar year 2018 and 564 facilities providing brachytherapy. Within the 306 HRRs in the US, 149 have access to brachytherapy. This represents 247.5 million people based on 2018 estimates of population from the US Census Bureau. This implies that 76.7% of people within the US live in an HRR with access to brachytherapy, and, conversely, that 75.3 million people (23.3%) do not. Numerically, counties in metropolitan areas were more likely to have access to brachytherapy than those outside of a metropolitan area. CONCLUSIONSGeographic disparities exist in access to brachytherapy; metropolitan counties are more likely to have access than non-metropolitan counties. We support continued development of databases of brachytherapy providers and programs that may support travel and lodging costs to minimize these disparities.

Below the Tip of the Iceberg: Examining Early Childhood Participation in SNAP and TANF from Birth to Age Six.

In the United States, the SNAP and TANF programs provide financial support to low-income households with children. Yet, little is known about the extent of this support over the early childhood period or how program participation varies by race (or ethnicity) and metropolitan county residence. We use administrative data from Virginia to document participation in SNAP and TANF among children born between 2007 and 2010 during their early childhood period, which we define here as birth to age six. We find that participation in SNAP is about four times greater than participation in TANF and that most children begin their connection with the social welfare system in their birth year. Children who participate earlier in life tend to stay connected over a longer portion of the early childhood period, although SNAP participation peaks around ages 3–4 while TANF peaks earlier, around ages 2–3. Most households on SNAP do not receive TANF, but only about 1 in 12 children on TANF do not receive SNAP. Finally, over the early childhood period, on average, just under 1 in 2 children in Virginia participated in SNAP or TANF but demography plays an important role in this process: The level of cumulative receipt is 1 in 4 among White children, 1 in 2 among Hispanic children but rises to 3 in 4 for Black children; cumulative receipt is also higher in nonmetropolitan counties than metropolitan counties. This study documents the reach of the existing social welfare system during the early childhood period, underlining the importance of race and space in twenty-first century America.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11113-021-09660-9.

COVID-19 risk mitigation behaviors among rural and urban community-dwelling older adults in summer, 2020.

PurposeRisk mitigation behaviors are important for older adults, who experience increased mortality risk from COVID‐19. We examined these reported behaviors among rural and urban community‐dwelling adults aged 65 and older.MethodsWe analyzed public use files from the National Health and Aging Trends Study, which fielded a COVID survey from June to October, 2020, restricted to community‐dwelling adults (n = 2,982). Eight behaviors were studied: handwashing, avoid touching face, mask wearing, limiting shopping, avoiding restaurants or bars, limiting gatherings, avoiding contact with those outside the household, and distancing. Residence was defined as urban (metropolitan county) or rural (nonmetropolitan county). Difference testing used Chi Square tests, with an alpha level of P = .05. Multivariable logistic regression was used to calculate adjusted odds ratios.ResultsRural residents constituted 18.8% (± Standard Error 3.6%) of the study population. In bivariate comparisons, rural older adults were less likely to report 5 of 8 studied behaviors: keep 6‐foot distance (rural: 88.3% ±1.0%, urban 93.2% ±.08%), limit gatherings (rural 87.5% ±1.8%; urban 91.6% ±0.8%), avoid restaurants/bars (rural 85.3% ±1.9%, urban 89.6% ±0.8%), avoid touching face (rural 83.1% ±2.3%, urban 88.6%, 0.8%), and avoid contact with those outside the household (rural 80.4% ±2.4%, urban 86.2% ±1.0%). After adjusting for demographic characteristics, only maintaining a 6‐foot distance remained lower among rural older adults (AOR 0.58, 95% CI: 0.42‐0.81).ConclusionsWithin older adults, reported compliance with recommended behaviors to limit the spread of COVID‐19 was high. Nonetheless, consistent rural shortfalls were noted. Findings highlight the need for rural‐specific messaging strategies for future public health emergencies.