Rural Census Tracts Research Articles

Individual- and environmental-level determinants of fruit and vegetable intakes in rural Georgia.

To investigate the ways in which food insecurity, food acquisition behaviors, and perceived and objective food access influence fruit and vegetable intakes among rural Georgians. A population-based survey was merged with USDA's Food Access Research Atlas, and multilevel modeling was used to determine individual-level (eg, food insecurity, food acquisition behaviors, perceived access) and environmental-level (eg, census tract food access) predictors of fruit and vegetable intakes. Twenty-four rural census tracts in 6 counties in Georgia, USA. One thousand four hundred and seventy-four adults. Residing in a low food access census tract was not associated with fruit or vegetable intake. Food insecurity had negative effects on both fruit and vegetable intakes. Perceived access to fresh fruits and vegetables was positively associated with fruit intake, and obtaining fresh fruits and vegetables from community or home gardens was positively associated with both fruit and vegetable intakes. Findings are unique from previous research on census tract-level fruit and vegetable determinants, underscoring the need for a better understanding of influences on fruit and vegetable intakes among rural populations. Interventions to increase fruit and vegetable consumption in rural areas should prioritize food security.

Geographic Variations in Urban‐Rural Particulate Matter (PM2.5) Concentrations in the United States, 2010–2019

AbstractFine particulate matter 2.5 (PM2.5) is a widely studied pollutant with substantial health impacts, yet little is known about the urban‐rural differences across the United States. Trends of PM2.5 in urban and rural census tracts between 2010 and 2019 were assessed alongside sociodemographic characteristics including race/ethnicity, poverty, and age. For 2010, we identified 13,474 rural tracts and 59,065 urban tracts. In 2019, 13,462 were rural and 59,055 urban. Urban tracts had significantly higher PM2.5 concentrations than rural tracts during this period. Levels of PM2.5 were lower in rural tracts compared to urban and fell more rapidly in rural than urban. Rural tract annual means for 2010 and 2019 were 8.51 [2.24] μg/m3 and 6.41 [1.29] μg/m3, respectively. Urban tract annual means for 2010 and 2019 were 9.56 [2.04] μg/m3 and 7.51 [1.40] μg/m3, respectively. Rural and urban majority Black communities had significantly higher PM2.5 pollution levels (10.19 [1.64] μg/m3 and 9.79 [1.10] μg/m3 respectively), in 2010. In 2019, they were: 7.75 [1.1] μg/m3 and 7.09 [0.78] μg/m3, respectively. Majority Hispanic communities had higher PM2.5 levels and were the highest urban concentration among all races/ethnicities (8.01 [1.73] μg/m3), however they were not the highest rural concentration among all races/ethnicities (6.22 [1.60] μg/m3) in 2019. Associations with higher levels of PM2.5 were found with communities in the poorest quartile and with higher proportions of residents age<15 years old. These findings suggest greater protections for those disproportionately exposed to PM2.5 are needed, such as, increasing the availability of low‐cost air quality monitors.

Access to community pharmacies based on drive time and by rurality across the contiguous United States

BackgroundConsidering that mail-order pharmacy use remains low in the United States, geographic accessibility of community pharmacies (pharmacy access) can have an outsized impact on a community’s access to services and care, especially among rural residents. However, previous measurements of pharmacy access rely on methods that do not capture all aspects of geographic access. ObjectivesThis study aimed to measure pharmacy access across the contiguous United States and by rural, suburban, and urban areas using drive-time analysis and an improved methodological approach. MethodsThe 2-step floating catchment area method was used to measure pharmacy access by considering the supply capacity of pharmacies, population demand for pharmacies, and the interaction between them within a reasonable travel time range. This method is a methodologically improved approach compared with previous methods for measuring geographic access. Network analysis was used to measure drive time from the population-weighted centroids of census tracts to the geocoded location of community pharmacies. Census tract-level pharmacy access was measured using a 10- and 20-minute drive time. Census tracts were also categorized based on population per square mile as rural (< 1000), suburban (1000-3000), and urban (> 3000). ResultsAcross the contiguous United States, 79.9% and 91.1% of census tracts had access to at least 1 pharmacy per 10,000 people within a 10- and 20-minute drive time, respectively. Rural census tracts had the lowest share of access to at least 1 pharmacy per 10,000 people compared with suburban and urban tracts and for both drive times. ConclusionCommunity pharmacies are highly accessible health care access points, specifically in urban and suburban areas. Pharmacies should be considered to expand access to services with limited geographic accessibility such as treatment programs for opioid use disorders, primary care, and healthy foods.

Opportunities to Improve Access to and Retention in the Child and Adult Care Food Program: Key Recommendations From Early Childcare Providers in Illinois, December 2020-July 2021.

Objectives. To identify recommendations to improve access to and retention in the Child and Adult Care Food Program (CACFP) as critical strategies to address health equity for low-income children. Methods. We conducted a qualitative key informant study of early childcare center and home providers (n = 35) in low-income urban and rural census tracts in Illinois between December 2020 and July 2021. Interviews with providers were organized and analyzed by the study team in MAXQDA Qualitative Data Analysis software. Themes were refined and finalized via member checking with an expert panel of providers and advocates. Results. Overall, providers spoke positively of the benefits of CACFP participation. Themes that centered around strategies to improve awareness of and access to CACFP included (1) conducting systematic statewide outreach, (2) improving technical assistance for enrollment, and (3) supporting positive sponsor-provider relationships. Themes related to retention included (1) alleviating procurement burdens, (2) extending reimbursement rates, and (3) expanding flexibilities. Conclusions. Policymakers looking to increase access to and retention in CACFP could consider state-level strategies such as systematic outreach and more targeted technical assistance. (Am J Public Health. 2024;113(S3):S231-S239. https://doi.org/10.2105/AJPH.2023.307433).

Geographic Distribution of Social Service Resources for Stroke Survivors in Ohio Varies by Rurality.

Both social service resources and stroke prevalence vary by geography, and health care resources are scarcer in rural areas. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of the highest stroke prevalence in Ohio and whether this is varied by rurality using an ecological study design. Census tract (CT)-level self-reported stroke prevalence estimates (Centers for Disease Control and Prevention PLACES-2019 Behavioral Risk Factor Surveillance System) were linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp data). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated the mean number of resources within 25 miles and 30 minutes of a CT centroid and quartiles of stroke prevalence for each resource group by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT demographics. In Ohio, stroke prevalence was 3.9% (0.4%-14.2%). The highest stroke prevalence quartile (versus lowest) was associated with fewer resources within 25 miles overall (resource ratio [RR], 0.57-0.98). The most pronounced disparities were in rural CT; rural CTs with the highest quartile stroke prevalence had fewer housing (RR, 0.49 [95% CI, 0.32-0.75]), in-home (RR, 0.31 [95% CI, 0.20-0.49]), and therapy (RR, 0.23 [95% CI, 0.13-0.43]) resources compared with those with the lowest quartile stroke prevalence (reference: mean, 1.2 housing, 5.1 in-home, and 4.9 therapy resources, respectively). Rural disparities no longer persisted after adjustment for federal poverty limit (rural: housing [RR, 0.69 (95% CI, 0.40-1.20)], in-home [RR, 0.65 (95% CI, 0.34-1.23)], and therapy [RR, 0.66 (95% CI, 0.33-1.32)]). Stroke social service resources are inversely distributed relative to stroke prevalence in Ohio, particularly in rural areas. This inverse link in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions may be needed and should consider the roles of rurality and poverty.

Abstract 406: Texas Out of Hospital Cardiac Arrest Disparities for Rural Patient Care From Statewide Out-of-Hospital Cardiac Arrest Data Registry - The Texas Cares Project

Introduction: Out-of-hospital cardiac (OHCA) arrest victims from rural settings suffer worse outcomes. We evaluated the association between rural setting and post-arrest care and outcomes. Hypothesis: Receiving treatment for OHCA at a rural hospital will be associated with a lower rate of post OHCA care and lower rate of favorable neurologic outcomes (cerebral performance score 1 or 2). Methods: We performed a retrospective analysis of the Texas Cardiac Arrest Registry to Enhance Survival (CARES) from 2014-2021. We included adult OHCAs not listed as DNR. We defined hospital urbanicity as the proportion of OHCAs originating from rural census tracts. We defined hospitals as rural if more than 25% of included OHCAs were rural. We evaluated the association between rural hospital status and patient and prehospital care characteristics - age, race, initial rhythm, response time, bystander CPR - and hospital care characteristics - targeted temperature management (TTM) and percutaneous coronary intervention (PCI) rates. We evaluated the association between rural hospital status and favorable neurological outcomes with logistic regression, adjusted for patient and prehospital factors, hospital care, and census tract median household income. Results: We included 31,569 encounters with OHCA at 161 unique hospitals. The rural hospital group included 1,213 OHCA encounters (3.8%) at 25 hospitals (15.5%). Patient factors between groups were similar other than a higher rate of white patients in the rural group. Rates of angiography (16.1% non rural, 17.1% rural), PCI (8.2%, 8.7%), and TTM (30.6%,34.7%) were not statistically different. Treatment at rural hospitals was not associated with a statistically significant decreased odds of good neurological outcome (aOR 1.02, 95%ci 0.83-1.24). Conclusion: Treatment for OHCA at rural hospitals was not associated with a lower rate of post OHCA care or lower rate of favorable neurologic outcome

Abstract 105: Rural-Urban Differences for Integrated First Responder and Drone Automated External Defibrillator Delivery in North Carolina

Background: Early defibrillation for out-of-hospital cardiac arrest (OHCA) can improve survival significantly, but timely access to AEDs remains a barrier especially in rural areas. We analyzed whether differences exist between urban and rural areas for a proposed program of first responder (FR) and drone AED delivery in North Carolina. Methods: Using CARES registry data, we identified OHCAs in 48 counties between Jan. 2013-Dec. 2019. We applied a hypothetical intervention in which 1) all FRs were provided AEDs and 2) a network of AED-carrying drones was optimized within each county to maximize &lt;5-minute response times (defined as the interval from 9-1-1 call receipt to arrival of an AED via EMS, FR, or drone). Within each county, we classified census tracts by rural population with &lt;25% as urban, 25-75% as mixed, and &gt;75% as rural. We included only counties with ≥10 OHCAs per year in both rural and urban census tracts to compare resource allocation for counties with large geographic variation. Historical and intervention response times stratified by rurality were compared via the Wilcoxon signed-rank test. Results: We included 19 counties and 8,955 OHCAs (5,754 urban, 3,201 rural). The historical median response time was 6.9 mins [IQR: 5.1-8.7] in urban census tracts and 9.4 mins [IQR: 7.0-12.1] in rural tracts. The FR + drone intervention reduced estimated median response times by 42% to 4.0 mins [IQR: 3.1-5.0] in urban areas and by 24% to 7.1 mins [IQR: 5.2-9.4] in rural areas. Five-minute coverage improved from 24% to 77% for urban areas and 10% to 23% for rural areas. All counties showed significant improvement in response time for both urban and rural populations (p&lt;0.01). Conclusion: Deployment of AEDs by FR and drones optimized for 5-minute coverage was estimated to improve AED response more so in urban areas than rural areas. Other optimization parameters are needed to reduce inequality between urban and rural response times in areas with large geographic variation.

Associations between PM2.5 and O3 exposures and new onset type 2 diabetes in regional and national samples in the United States

BackgroundExposure to particulate matter ≤2.5 μm in diameter (PM2.5) and ozone (O3) has been linked to numerous harmful health outcomes. While epidemiologic evidence has suggested a positive association with type 2 diabetes (T2D), there is heterogeneity in findings. We evaluated exposures to PM2.5 and O3 across three large samples in the US using a harmonized approach for exposure assignment and covariate adjustment. MethodsData were obtained from the Veterans Administration Diabetes Risk (VADR) cohort (electronic health records [EHRs]), the Reasons for Geographic and Racial Disparities in Stroke (REGARDS) cohort (primary data collection), and the Geisinger health system (EHRs), and reflect the years 2003–2016 (REGARDS) and 2008–2016 (VADR and Geisinger). New onset T2D was ascertained using EHR information on medication orders, laboratory results, and T2D diagnoses (VADR and Geisinger) or report of T2D medication or diagnosis and/or elevated blood glucose levels (REGARDS). Exposure was assigned using pollutant annual averages from the Downscaler model. Models stratified by community type (higher density urban, lower density urban, suburban/small town, or rural census tracts) evaluated likelihood of new onset T2D in each study sample in single- and two-pollutant models of PM2.5 and O3. ResultsIn two pollutant models, associations of PM2.5, and new onset T2D were null in the REGARDS cohort except for in suburban/small town community types in models that also adjusted for NSEE, with an odds ratio (95% CI) of 1.51 (1.01, 2.25) per 5 μg/m3 of PM2.5. Results in the Geisinger sample were null. VADR sample results evidenced nonlinear associations for both pollutants; the shape of the association was dependent on community type. ConclusionsAssociations between PM2.5, O3 and new onset T2D differed across three large study samples in the US. None of the results from any of the three study populations found strong and clear positive associations.

Refining large-scale spatial metrics of food access

Large scale metrics of food access are frequently used to identify spatial inequities and for targeting local government intervention. The Food Access Research Atlas by the USDA and the Modified Retail Food Environment Index by the CDC are two such measures frequently used at the census-tract level. This paper uses spatial analyses to identify ways in which they can be refined for better actionability. Outcomes from this paper are threefold: (i) Upon examination of the average food environment, it finds that we might be undercounting rural census tracts with low food access relative to urban tracts; (ii) Disaggregating the often-conflated goals of physical access for food equity and nutritional access for public health might help targeting interventions; (iii) Data on food environments, and underlying assumptions on food consumption behavior should be investigated with greater caution.

Ethnic Disparities in Early-Onset Gastric Cancer Persist across Rural-Urban Geographies.

The incidence of noncardia gastric cancer is increasing in adults ages less than 50 years old. Early-onset gastric cancer (EOGC) is characterized by ethnic disparities occurring more in Hispanic persons than non-Hispanic persons. It is unknown whether rural-urban disparities exist in EOGC and if this intersects with ethnic disparities. We utilized the Surveillance Epidemiology and End Results 17 Census Tract-level Socioeconomic Status and Rurality Database from 2006 to 2018 to calculate incidence rates and incidence rate ratios of EOGC among Hispanic and non-Hispanic persons by census tract rural-urban location, age, gender, persistent poverty, and stage of disease. We used the Tiwari Method to estimate incidence rate ratios with 95% confidence intervals (CI). Hispanic persons had higher incidence rates of EOGC compared with non-Hispanic persons in both rural [incident rate ratios (IRR), 2.12; 95% confidence interval (CI), 1.64-2.73] and urban census tracts (IRR, 2.03; 95% CI, 1.91-2.16). Similar findings were seen when comparing Hispanic to non-Hispanic persons in rural and urban census tracts by age, stage of disease, and persistent poverty. Higher incidence rates of EOGC among Hispanic persons persist across rural-urban locations. Further research is needed to understand the etiology of this elevated risk in young Hispanics and interventions that may help to modify their outcome. While other cancers have ethnic disparities which may differ by rural-urban location, the ethnic disparity in EOGC among Hispanic and non-Hispanic persons does not differ by rural-urban residence.

Drive Time to Addiction Treatment Facilities Providing Contingency Management across Rural and Urban Census Tracts in 6 US States.

We examined drive times to outpatient substance use disorder treatment providers that provide contingency management (CM) and those that integrate CM with medication for opioid use disorder (MOUD) services in 6 US states. We completed cross-sectional geospatial analysis among census tracts in Delaware, Louisiana, Massachusetts, North Carolina, New York, and West Virginia. We excluded census tracts with a population of zero. Using data from the 2020 Shatterproof substance use treatment facility survey, our outcome was the minimum drive time in minutes from the census tract mean center of population to the nearest outpatient CM provider, outpatient CM provider with MOUD services, and federally qualified health centers (FQHC). We stratified census tracts by 2010 Rural-Urban Commuting Area codes and by state. The population was greater than zero in 11,719 of 11,899 census tracts. The median drive time to the nearest CM provider was 12.2 [interquartile range (IQR), 7.0-23.5) minutes and the median drive time to the nearest CM provider increased from 9.7 (IQR, 6.0-15.0) minutes in urban census tracts to 38.8 (IQR, 25.4-53.0) minutes in rural ( H = 3683, P < 0.001). The median drive time increased to the nearest CM provider with MOUD services [14.2 (IQR, 7.9-29.5) minutes, W = 18,877, P < 0.001] and decreased to the nearest FQHC [7.9 (IQR, 4.3-13.6) minutes, W = 11,555,894, P < 0.001]. These results suggest limited availability of CM, particularly within rural communities and for patients needing concurrent CM and MOUD treatment. Our results suggest greater adoption of CM within FQHCs could reduce urban-rural disparities in CM availability.

Abstract 45: Geographic Distribution Of Social Service Resources For Stroke Survivors In Ohio Varies By Rurality

Introduction: The availability of social services resources and stroke prevalence vary by geography. We assessed whether distributions of resources relevant to stroke survivors were clustered around areas of highest stroke prevalence in Ohio and if this varied by rurality. Methods: Census tract (CT) level self-reported stroke prevalence estimates (CDC PLACES-2019 Behavioral Risk Factor Surveillance System) was linked with sociodemographic and rurality data (2019 American Community Survey) and geographic density of resources in Ohio (2020 findhelp—search engine connecting individuals to a network of area social services). Resources were grouped into categories: housing, in-home, financial, transportation, education, and therapy. Negative binomial regression models estimated mean number of resources within 25 miles of a CT centroid and quartiles of stroke prevalence for each resource group and stratified by rurality status (rural, urban, and suburban). Models were sequentially adjusted for total population and CT level demographics. Results: The highest stroke prevalence quartile was associated with fewer resources within 25 miles compared to the lowest quartile overall (Prevalence Ratios (PR): 0.57-0.98), but this varied by rurality with the most pronounced disparity in rural CT ( p &lt;0.05 for all resource categories). Rural CTs with the highest quartile stroke prevalence had fewer housing PR: 0.49 (95% CI: 0.32, 0.75), in-home PR: 0.31 (0.20, 0.49), and therapy PR: 0.23 (0.13, 0.43) resources compared to those with the lowest quartile stroke prevalence. Rural disparities became null after adjustment for federal poverty limit (FPL), supporting FPL as a mediator of this association. Conclusions: The inverse link between stroke prevalence and resource availability in rural Ohio is likely explained by geographic differences in poverty. Stroke-specific resource-related interventions are likely needed and should consider the role poverty.

Analyzing the risk factors of residential fires in urban and rural census tracts of Ohio using panel data analysis

Analyzing the risk factors of residential fires in urban and rural census tracts of Ohio using panel data analysis

Slipped Capital Femoral Epiphysis, Food Deserts, Poverty, and Urban/Rural Residence: Is There a Link?

Childhood obesity is increased in food deserts, a community with little to no access to healthy food. As obesity is associated with slipped capital femoral epiphysis (SCFE), it was the purpose of this study to analyze the prevalence of SCFE patients by food desert location and its interaction with rural/urban location. A retrospective review of all consecutive patients with idiopathic SCFE treated at our institution over 11 years was performed. From the patient's address, the US Census Bureau tract in which the patient resided was determined. Using the census tract code, it was ascertained if the patient lived in a food desert and urban or rural location. Standard statistical analyses were performed; a P <0.05 was considered statistically significant. There were 177 SCFE patients: 79 girls, 98 boys, 106, White, and 69 nonWhite. The average age at diagnosis was 12.1±1.7 years, the average symptom duration 4.1±5.1 months, and the average weight percentile 94±10. Of these 177 patients, 26.5% lived in a food desert, which was higher than the expected 17.5% ( P =0.023). Those living in a food desert were more commonly nonWhite (60% vs. 32%, P =0.0014). There were 25% from rural areas and 75% from urban areas. No rural SCFE patients lived in food deserts whereas 34% of urban patients lived in food deserts. The average poverty rate of the SCFE patient census tracts was 19%, no greater than the expected 15% ( P =0.32). SCFE patients living in rural census tracts had a lower poverty rate ( P <10 -6 ). There is a correlation with the prevalence of SCFE patients by residence in a "food desert", but not with rural/urban locale or poverty status in Indiana. Further research will be needed to see if these findings apply to other states within the United States and other parts of the world. III.

Identifying community-level disparities in access to driver education and training: Toward a definition of driver training deserts

Objective Obtaining a license may be challenging for teens due to access to driving instruction; in some states, behind-the-wheel (BTW) instruction is required to secure a license before age 18. We investigate spatial accessibility to BTW centers, and how this geographic distribution intersects with metrics of social disparity at the metropolitan level, toward identifying Driver Training Deserts (DTDs): geographic areas of disconnection to driver training. Methods For the Columbus OH region, we collect socioeconomic variables at the Census tract unit of analysis and geocoded locations of public and private BTW training centers and estimate travel time to the nearest BTW training center. We define travel time as either the mean or the maximum travel time to BTW centers across all 1 km × 1 km grid cells within a Census tract. We employ spatial statistical approaches, including homogeneous/inhomogeneous K functions, to determine whether BTW training centers are clustered. Next, we define DTDs as Census tracts with a poverty rate and travel time to BTW centers larger than the 75th percentile values across the region. Results BTW training centers are spatially clustered across the region; the magnitude of this clustering is so great that BTW centers exhibit statistically significant patterns of clustering, even when considering the underlying spatial distribution of socio-economic characteristics. We find that 11–27 Census tracts are identified as DTDs depending on the definition of travel time. DTDs contain a disproportionate percent of the high poverty population (8.7–23.5%) and, depending on the definition of travel time, a disproportionately large African American population. Conclusions Methodologically, defining DTDs necessitates a fine-grained spatial approach as suburban and rural Census tracts tend to be large and thus can be poorly represented by travel times averaged over the Census tract. Defining DTDs as a measure of individual-specific variables – income and impedance – allows DTDs to be addressed with policy interventions. The findings motivate future research correlating DTDs with licensure rates, enrollment in driver training, and safe driving outcomes to understand if DTDs can help explain health equity outcomes related to young driver safety.

Challenging terrains: socio-spatial analysis of Primary Health Care Access Disparities in West Virginia.

Challenging terrains: socio-spatial analysis of Primary Health Care Access Disparities in West Virginia.

Adolescent Access to Federally Funded Clinics Providing Confidential Family Planning Following Changes to Title X Funding Regulations

In May 2019, new federal regulations regarding Title X funding were introduced. There has been no formal evaluation of the impact of this regulatory shift as it pertains to minors' access to services. To explore the geography of federally funded clinics providing confidential reproductive care to adolescents following changes to Title X funding regulations. This retrospective cross-sectional study used a population-based sample of US Census tracts. All clinics participating in the Title X program in August 2018 and August 2020 were included in the analysis. Data were analyzed from January to December 2021. Period, defined as before and after the 2019 Title X rule change (August 2018 and August 2020, respectively). US Census tracts were evaluated for the availability of confidential family planning care within a 30-minute drive, according to the presence of a Title X clinic or a permissive state law. Census tracts in which minors lost access to confidential care after the rule change were characterized in terms of demographic characteristics. Univariate logistic regression evaluated associations between Census tract characteristics and the odds of losing vs maintaining access to legally protected confidential minor services. The study included 72 620 Census tracts, accounting for approximately 324 697 728 US residents (99.96% of the population). After the Title X rule change, 1743 clinics in the Title X program left (39.0%) and minors living in 6299 Census tracts (8.7%) lost access to confidential family planning care, corresponding to an estimated 933 649 youth aged 15 to 17 years. Minors living in rural Census tracts (odds ratio [OR], 1.27; 95% CI, 1.18-1.36) and those in the Midwest (OR, 2.41; 95% CI, 2.24-2.60) had higher odds of losing access to care. Minors living in Census tracts with a higher Social Vulnerability Index (OR, 0.51; 95% CI, 0.47-0.55), a larger proportion of Black individuals (OR, 0.34; 95% CI, 0.31-0.37), and/or a larger proportion of Hispanic individuals (OR, 0.45; 95% CI, 0.42-0.49) were less likely to lose access to care. These findings suggest that there were losses in access to legally protected confidential reproductive health services for youth after the 2019 Title X rule change. Although evidence-based Title X guidelines have since been reinstated, state laws that ensure adolescent confidentiality in obtaining family planning services may protect youth from future alterations to the Title X program.

Factors Predictive of Primary Therapeutic Modality in Early-Stage Oropharyngeal Squamous Cell Carcinoma

<h3>Purpose/Objective(s)</h3> Traditionally, definitive radiotherapy (RT) was the preferred treatment for oropharyngeal squamous cell carcinoma (OPSCC). Changes in both surgical technology (the advent of transoral robotic surgery) and the pathogenesis of the disease (increase in patients with HPV-associated disease) have altered this paradigm. We aimed to assess factors influencing the use of definitive surgery versus RT among patients with early stage OPSCC. <h3>Materials/Methods</h3> We used the Surveillance, Epidemiology, and End Results (SEER) Head and Neck with HPV Status Database along with the SEER Census Tract-level Socioeconomic Status (SES) and Rurality Database. From 40,787 patients treated from 2010 – 2016, we identified 9,292 who met inclusion criteria (T0-3, N0-2, M0 disease with known status for all variables included in our model). Patients undergoing pharyngectomy were deemed to have definitive surgery. Those receiving RT in the absence of a pharyngectomy were deemed to have definitive RT. We performed a multivariable logistic regression for factors correlated with definitive RT. Our model initially included age and year of diagnosis, gender, race, primary site, T- and N-classification, HPV status, marital status, rural/urban status, and socioeconomic status (SES) as indicated by Yost index. We used a backwards stepwise selection algorithm until no variable had a p value > 0.10; the final model included all variables except gender, race, and year of diagnosis. <h3>Results</h3> 6,008 patients (64.7%) received definitive RT and 3,284 (35.3%) received definitive surgery. Of those receiving definitive surgery, 2,510 (76.4%) also received RT. On multivariable logistic regression, higher T- or N-classification and non-tonsillar fossa primary site significantly increased the likelihood of definitive RT. Patients with HPV-positive disease were less likely to receive definitive RT (odds ratio (OR) = 0.87, 95% CI 0.77 – 0.98, p = 0.021). Patients in entirely rural census tracts were less likely to receive definitive RT (OR = 0.81, 95% CI 0.67 – 0.99, p = 0.042). Those living in census tracts in the lowest SES tertile were more likely to receive definitive RT (OR = 1.17, 95% CI 1.02 – 1.33, p = 0.014). <h3>Conclusion</h3> We identified sociodemographic and clinical factors associated with primary treatment for early stage OPSCC. Tumor size and primary site, appear to influence treatment allocation; however, non-clinical factors may also play a role. Patients living in rural areas are more likely to receive definitive surgery; patients in lower SES areas are more likely to receive definitive RT. Further investigation into these differences is warranted to ensure equal access to all therapeutic options for patients with early stage OPSCC.

Residential green space and mental health-related prescription medication sales: An ecological study in Belgium

BackgroundResidential green space has been associated with mental health benefits, but how such associations vary with green space types is insufficiently known. ObjectiveWe aimed to investigate associations between types and quantities of green space and sales of mood disorder medication in Belgium. MethodsWe used aggregated sales data of psycholeptics and psychoanaleptics prescribed to adults from 2006 to 2014. Generalized mixed effects models were used to investigate associations between relative covers of woodland, low-green, grassland, and garden, and average annual medication sales. Models were adjusted for socio-economic background variables, urban-rural differences, and administrative region, and included random effects of latitude and longitude. ResultsUrban census tracts were associated with 9–10% higher medication sales. In nationwide models, a 10% increase in relative cover of woodland, garden, and grass was associated with a 1–2% decrease in medication sales. The same association was found for low green but only for men. In stratified models, a 10% increase in relative cover of any green space type in urban census tracts was associated with a decrease of medication sales by 1–3%. In rural census tracts, no protective associations between green space and mood disorder medication sales were observed, with the exception of relative woodland cover for women (−1%), and low green was associated with higher medication sales (+6–7%). ConclusionsTaken together, these results suggest that living in green environments may be beneficial for adult mental health. Woodland exposure seemed the most beneficial, but the amount of green space was more important than the type. Results underline the importance of conserving green space in our living environment, for the conservation of biodiversity and for human health.

Neighborhood Walkability and Physical and Mental Health among Older Adults Living in a Deprived Community

Background: Identifying the factors to improve the quality of life (QOL) is vital to decrease morbidity and mortality rates among older adults. Although unfavorable neighborhood features have a significant negative impact on QOL, few studies have investigated these relationships in a deprived community. The purpose of the study was to understand how neighborhood walkability is associated with QOL using the SF-36 among urban-dwelling older adults. Methods: This is a cross-sectional survey. Participants were recruited in 2018 and 2019 at regional health clinics in Flint, MI. To be eligible, participants had to be over 65 years old and Flint residents. Results: Of the 132 participants, the majority were female (66%), African American (77%), single, divorced, or widowed (75%), and educated below GED level (84%). After adjusting for gender, assistive device use, medication, and the Supplemental Security Income receipt, multiple regression analysis revealed that those with better perceptions of land-mixed use and accessibility within their neighborhood were more likely to have better physical health (β = .36, p<.05). However, the perceptions of greater pedestrian safety were associated with the poor physical and mental health (PCS; β = -0.19, p <.05; MCS; β = -0.25, p < .05). Perceptions of the presence of walking hazards and crime were not significantly associated with QOL. Discussion: Findings suggest that neighborhood walkability characteristics are associated with physical health. The development of walking programs with accessible neighborhoods will be urgent to improve the health-related QOL for older adults living in a targeted community.