Rural-urban Continuum Research Articles

Measuring rurality in health services research: a scoping review

PurposeThis study is a scoping review of the different methods used to measure rurality in the health services research (HSR) literature.MethodsWe identified peer-reviewed empirical studies from 2010–2020 from seven leading HSR journals, including the Journal of Rural Health, that used any definition to measure rurality as a part of their analysis. From each study, we identified the geographic unit (e.g., county, zip code) and definition (e.g., Rural Urban Continuum Codes, Rural Urban Commuting Areas) used to classify categories of rurality. We analyzed whether geographic units and definitions used to classify rurality differed by focus area of studies, including costs, quality, and access to care. Lastly, we examined the number of rural categories used by authors to assess rural areas.FindingsIn 103 included studies, five different geographic units and 11 definitions were used to measure rurality. The most common geographic units used to measure rurality were county (n = 59, 57%), which was used most frequently in studies examining cost (n = 12, 75%) and access (n = 33, 57.9%). Rural Urban Commuting Area codes were the most common definition used to measure rurality for studies examining access (n = 13, 22.8%) and quality (n = 10, 44%). The majority of included studies made rural versus urban comparisons (n = 82, 80%) as opposed to focusing on rural populations only (n = 21, 20%). Among studies that compared rural and urban populations, most studies used only one category to identify rural locations (n = 49 of 82 studies, 60%).ConclusionGeographic units and definitions to determine rurality were used inconsistently within and across studies with an HSR focus. This finding may affect how health disparities by rural location are determined and thus how resources and federal funds are allocated. Future research should focus on developing a standardized system to determine under what circumstances researchers should use different geographic units and methods to determine rurality by HSR focus area.

Undergraduate Vaccine Hesitancy and the Influence of "Home" Locales.

In the US, the COVID-19 pandemic has exposed deeply rooted resistance to public health. This has important consequences for SARS-CoV-2 variant spread and for future uptake of influenza and other vaccines. We examine these phenomena in Missouri, where its low vaccination rates, high levels of uninsured residents, predominance of conservative values, and stark rural-urban divides are intricately connected to public health resistance. The Socio-Ecological model guides our approach. We use data from the Fall 2020 Midwestern University (MWU-a pseudonym) Study of Seropositivity and Risk for SARS-CoV-2 and COVID-19 which are harmonized with the American Community Survey, Missouri County-Level Study, and the USDA Rural-Urban Continuum Codes to estimate multi-level regression models on the relationship between undergraduate students' "home" locales and their own COVID-19 and influenza vaccine hesitancy. The availability of primary care physicians, the prevalence of influenza vaccinations, and location type at the county level, as well as the percentage of residents without health insurance at the zip code level differentially predict COVID-19 and influenza vaccine hesitancy. There is a link between county-level health and geographic characteristics, and individuals'-who were influenced by those counties because that is where their parents live-hesitancy towards vaccines. Identifying feasible, precise, local solutions to reducing vaccine hesitancy could take place if community members and other stakeholders would be open to changes in local-level health policy or practice.

Rural Residence is Associated With a Delayed Trend Away From Sulfonylurea Use for Treatment Intensification of Type 2 Diabetes

Where a person resides may impact the health care they receive. Using a process-based approach, we examined the interplay between location of residence along the rural-urban continuum (metropolitan/urban/rural) and sulfonylurea (SU) dispensation records for the management of type 2 diabetes. This retrospective cohort study used administrative health records of adult new metformin users between April 2008–March 2019 in Alberta. Multivariate logistic regression was performed to examine the association between SU-based treatment intensification and location of residence.

Evidence of Geospatial and Socioeconomic Disparities in Access to Online Grocery Shopping for Fresh and Frozen Produce in North Carolina

Online grocery shopping is a rapidly growing food procurement approach in the United States with the potential to improve food access. Limited research has focused on understanding differential access to online grocery shopping that provides healthier items such as fresh or frozen fruits and vegetables. The study aim was to understand geospatial, socioeconomic, and racial disparities in the availability of healthy online grocery shopping and online Supplemental Nutrition Assistance Program (SNAP) acceptance in North Carolina. A cross-sectional study was conducted during spring2021. A listing of grocery stores with online shopping was generated using a systematic search strategy. Stores were geocoded and spatially joined to relevant contextual (rural/urban [based on US Department of Agriculture Rural Urban Continuum codes]), broadband Internet availability, socioeconomic variables (ie, percent poverty and Social Vulnerability Index), and demographic variables (ie, percent racial minority) in geographic information systems software. Prevalence rate ratios (PRRs) of healthy online grocery shopping (availability of curbside pickup or home delivery of fresh and frozen produce), and online SNAP acceptance (ie, availability of online SNAP), at the census tract level (n= 2,162). PRRs for availability of healthy online grocery shopping and SNAP online acceptance at the census tract level (n= 2,162) were modeled using Poisson regression with robust standard errors. This study found disparities in access to healthy online grocery shopping and SNAP online shopping availability in North Carolina. Healthy online shopping availability rates were higher in urban census tracts (PRR 1.68, 95% CI 1.47 to 1.92), areas with lower Social Vulnerability Index scores (PRR 0.99, 95% CI 0.98 to 0.99), higher Internet Availability Index scores (PRR 1.21, 95% CI 1.17 to 1.25), and lower percent poverty (PRR 0.94, 95% CI 0.90 to 0.98). SNAP online shopping availability rates were higher in urban census tracts (PRR 1.41, 95% CI 1.16 to 1.65), areas with higher Social Vulnerability Index scores (PRR 1.02, 95% CI 1.01 to 1.04), higher Internet Availability Index scores (PRR 1.15, 95% CI 1.10 to 1.20), and higher percent minority (PRR 1.02, 95% CI 1.0001 to 1.03). SNAP online shopping availability rates were lower in areas with higher percent poverty (PRR 0.90, 95% CI 0.85 to 0.95). This study found disparities in access to healthy online grocery shopping and SNAP online shopping for rural areas, and areas with higher poverty, and lower broadband Internet access in North Carolina. Further research is needed to identify effective strategies for addressing these disparities.

Geographic Employment Outcomes for Graduating Residents in Radiation Oncology: 2021

PurposeIn light of the persistent disparity in the prevalence of radiation oncologists between rural and urban areas in the United States, we sought to characterize the geographic employment outcomes of the radiation oncology (RO) residency class of 2021. Methods and MaterialsWe identified the employment positions accepted by 2021 RO residency graduates using publicly available information. Then, we classified each position as academic or nonacademic and determined the rural–urban continuum code and core-based statistical area (CBSA) of each position, residency program, and medical school associated with the 2021 graduates. Last, we compared the geographic employment outcomes of the 2021 class with those of the 2019 class. ResultsMost 2021 graduates accepted employment positions outside of the counties, CBSAs, and states in which they attended medical school or residency. A total of 116 graduates accepted nonacademic positions, and 65 graduates accepted academic positions. Nine graduates accepted fellowships and were excluded from this analysis. As with the class of 2019, most 2021 graduates (n = 104; 57.5%) accepted positions in the largest metropolitan areas, and few (n = 11; 6.1%) accepted positions in nonmetropolitan areas. Female residents were more likely to accept academic (48.9% vs 31.3%; P = .03) and academic main site (36.2% vs 21.6%; P = .05) positions than male residents. The distribution of jobs in both the 5 and 10 largest CBSAs was not significantly different from what would have been expected if jobs were equally distributed across the country on the basis of population (P = .81 and P = .87, respectively). However, the distribution was significantly different from what would have been expected if the distribution of such positions reflected the number of residents who graduated from residency programs in those CBSAs (P < .01 and P < .01, respectively). ConclusionsAs with the class of 2019, the majority of graduates in the class of 2021 accepted employment positions in large metropolitan areas. Relatively few graduates accepted positions in nonmetropolitan areas. How key RO stakeholders respond to the challenge of maintaining a stable supply of rural radiation oncologists while also ensuring that jobs available to graduating RO residents reflect their preferences will have a significant effect on the field going forward.

Predictors of Interstitial Brachytherapy Utilization in Locally Advanced Cervical Cancer and Impact on Overall Survival

<h3>Purpose/Objective(s)</h3> The standard of care for locally advanced cervical cancer (LACC) is multimodality therapy with chemotherapy, external beam radiation therapy (EBRT) and brachytherapy (BT) boost. The addition of BT improves overall survival (OS); interstitial BT has been prospectively shown to improve target and organ at risk dose, especially for larger tumors. Prior research suggests declining utilization of BT particularly in patients without insurance, underrepresented minorities, and in low volume cancer centers, which may widen cancer disparities. Here we utilize the National Cancer Database (NCDB) to examine patterns and predictors of BT use, particularly interstitial BT, in patients with LACC and its impact on OS. <h3>Materials/Methods</h3> The NCDB was used to identify patients with LACC (stage IIb-IVa) diagnosed between 2004-2018 and treated with radiation that included a component of BT. A multivariable model to predict receipt of interstitial vs intracavitary BT was created including age, race, comorbidity score (CCI), stage, receipt of chemotherapy, urban-rural continuum, insurance, facility type, facility region, facility quartile of cases reported and year of diagnosis. For survival analysis, patients who received interstitial BT were propensity score matched 1:1 to intracavitary patients using the same variables and nearest neighbor matching without replacement. Log rank survival analysis was performed for the matched cohort. <h3>Results</h3> A total of 9,591 patients were included with median age of 55 years. Overall, 14% of patients who received BT as part of their radiation treatment received interstitial BT. Ninety-three percent of patients received chemotherapy. On multivariable logistic regression analysis, higher stage (stage IIIa: OR 2.04 [95% CI 1.64 to 2.54], stage IIIb: OR 1.38 [1.22-1.57], stage IVa: OR 2.09 [1.09-4.00]), treatment at an academic center (OR 1.31 [1.12-1.54]), treatment at a higher volume center (highest quartile: OR 1.38 [1.12-1.70]) and later year of diagnosis (OR 1.03 per year [1.02-1.05]) were associated with increased interstitial BT utilization. Conversely, uninsured status (OR 0.772 [0.62-0.97]) or Medicare (OR 0.78 [0.65-0.94]) were associated with decreased interstitial BT utilization. There was no significant association between age at diagnosis, race, or CCI and patterns of interstitial BT use. After propensity score matching there was no overall survival difference between patients who received interstitial vs those treated with intracavitary BT (p=0.471). <h3>Conclusion</h3> Patients with more locally advanced cervical cancer and those treated at a high volume or academic center were more likely to receive interstitial BT. This pattern likely reflects appropriate intensification of therapy for larger tumors at centers with the expertise to perform interstitial implants. Utilization of interstitial implant did not translate into an OS benefit likely due to selection of cases for interstitial implant that have poor initial response to chemoRT.

The end of urban sprawl? Internal migration across the rural-urban continuum in Switzerland, 1966-2018.

In high-income countries, migration redistributed populations from congested city centres into the sparsely populated outskirts, raising challenges to environmental and population health and the conservation of biodiversity. We evaluate whether this periurbanisation process came to a halt in Switzerland by expecting a decline in internal migration and a renewed residential attractiveness of urban agglomeration centres (i.e., re-urbanisation)-two recent trend changes observed in Europe. Relying on data from censuses, registers and surveys, we describe trends in the intensity, geography and sociodemographic differentials of migration across consistently defined urban agglomeration density zones between 1966 and 2018. Although the overall intensity of migration declined, the rate increased among the working age population in part because of the societal diffusion of tertiary education. The dominant urban-bound migration flows are increasingly confined within agglomerations over time. After the diffusion of periurbanisation down the city hierarchy between 1966 and 1990, we observe the emergence of re-urbanisation in some agglomerations and sociodemographic groups around 2000. However, this phenomenon has been temporarily inflated by period-specific transformations in Swiss society. More recently, the process of periurbanisation intensified again and expanded more and more beyond official agglomeration borders.

Outcomes in Necrotizing Soft Tissue Infections Are Worse in Rural vs Urban Montana: A 10-Year Single Center Retrospective Review

Introduction: Time to definitive surgical debridement has been identified as a predictor for morbidity and mortality in necrotizing soft-tissue infections (NSTI). Rural patients are particularly at risk due to limited local resources, prolonged transport times, and access to care. The aim was to examine the outcomes of NSTI requiring surgical treatment within the context of Montana’s diverse urban-rural and racial setting. Methods: This retrospective study (2010-2020) explored electronic patient hospital records ≥18 years old with a NSTI (via ICD9/10 code) in Montana. Rural-Urban Continuum Codes (RUCC; characterizing counties by population size) were used to distinguish urban (≤3) to rural (≥4) counties, and race (American Indian/Alaskan Native (AI/AN) and White) self-described. Variables compared using 2-tailed statistical tests. Results: A total of 177 patients were identified. There was a significantly lower patient average age in AI/AN compared with White patients with no preexisting condition delineation. Diabetes was significantly higher in rural vs urban patients. NSTI infections showed a higher incidence in both rural areas and AI/AN patients. In addition, these two groups showed extended distance for treatment. White patients had a significantly different infection location than AI/AN. Further, polymicrobial species were significantly more prevalent in AI/AN patients. Morbidities (defined as amputation and/ or septic shock) were significantly increased in rural environments and AI/AN patients. There was no significant difference in all-cause mortality between groups. Conclusion: With diverse geography, excessive distances to regional trauma facilities, and distinct racial make-up, the state of Montana presents unique challenges to optimizing NSTI treatment and outcomes.

One Decade Later: The Generalizability, Diversity, and Inclusion of Community Health Needs Assessments.

The 2010 Patient Protection and Affordable Care Act aimed to reduce health disparities and change medicine to be more community-driven. To maintain tax-exempt status, hospitals must complete a Community Health Needs Assessment (CHNA) every 3 years. This assessment must ( a ) integrate input from individuals the community serves, ( b ) make the report publicly assessable, and ( c ) adopt an implementation strategy based on community health needs identified in the assessment. However, there is little information on how representative CHNAs are of the community. A content analysis was performed on a random sample of CHNA reports. This investigation examined nonprofit hospitals across the United States. This investigation analyzed the quality of CHNAs and described existing CHNA practices through 4 means: (1) identified the type of data included; (2) examined the frequency in the methods of data collection; (3) understood how representative those data are of the hospital's service region; and (4) explored to what extent the hospital addressed diversity and inclusion such as through recruitment. A stratified random sample was drawn of CHNAs published in the past 3 years (n = 450 reports). The sample was stratified by the US Department of Agriculture's Rural-Urban Continuum codes to balance hospital representation from metro and nonmetro areas. A series of dependent t tests revealed that these hospitals' reports represented a significantly more female, White, college-educated, and older population than the service area. In addition, only 3.12% of hospitals collected primary youth data. Finally, results also found that survey recruitment was not inclusive of individuals who did not have Internet access, could not read, or did not speak English fluently.

Socioeconomic vulnerability and public water arsenic concentrations across the US

Background/Aim: Inorganic arsenic is known human carcinogen and is routinely detected in community water systems (CWSs) across the US. Significant inequalities in CWS arsenic concentrations exist across broad sociodemographic subgroups of the US population. We evaluated the county-level association between socioeconomic vulnerability and CWS arsenic concentrations across the conterminous US. Methods: We evaluated previously developed, population-weighted, county-level CWS arsenic concentrations (2006-2011), the Centers for Disease Control and Prevention’s county-level socioeconomic vulnerability score (range: 0-1), median household income, and the proportion of adults with a high school diploma for 2,604 conterminous US counties. We used spatial lag models and evaluated the adjusted geometric mean ratio (GMR) of county-level CWS arsenic concentrations per interquartile range increase in socioeconomic vulnerability domain and in flexible spline models. We also stratified by region and by United States Department of Agriculture Rural-Urban Continuum Codes to assess potential effect measure modification by region and rurality. Results: Associations between socioeconomic vulnerability and CWS arsenic were modified by region, rurality, and socioeconomic domain. The fully adjusted GMR (95% CIs) of CWS arsenic per interquartile range increase in the proportion of adults with a high school education was 0.83 (0.71, 0.98) or 17% in the Southwest, 0.82 (0.71, 0.94) or 18% in the Eastern Midwest, and 0.65 (0.31, 1.36) or 35% in New England. Higher overall socioeconomic vulnerability was significantly associated with lower CWS arsenic, but only in counties in the Central Midwest and those with total populations less than 20,000. Conclusions: Higher educational attainment was associated with lower CWS arsenic in the Southwest, Eastern Midwest, and New England regions. Findings likely reflect regional/local differences in both socioeconomic/socio-cultural context and regulated drinking water contaminant concentrations. Region-specific analyses at finer geographic resolutions evaluating components of overall socioeconomic vulnerability are needed to adequately characterize the association. arsenic; drinking water; environmental justice

A Green Infrastructure Planning Approach: Improving Territorial Cohesion through Urban-Rural Landscape in Vojvodina, Serbia

Spatial and urban planning are directed towards achieving territorial cohesion as one of the sustainable development goals. Considering the hybrid concept of green infrastructure, this paper aims to provide an “ecological model” of achieving territorial cohesion in spatial and urban planning. Based on the connectivity level analysis between green infrastructure elements (green infrastructure hubs, nodes, gateways and dots), application of the GI concept guides the development of spatial planning scenarios. The application of Voronoi diagrams and landscape graph-based principles contribute to defining the shortest distances between green infrastructure elements, which resulted in the definition of the significance of structural and functional arrangement of green infrastructure dots in the matrix of the urban rural continuum in the territory of the urban-rural landscape of three case studies in Vojvodina, Serbia (Novi Sad, Subotica, Zrenjanin). As a result of this study, green infrastructure dots showed a great potential of application at the local level by developing them through landscape design with creative and artistic elements in order to achieve higher level of cohesion through visual attractivity, multifunctionality and recreation. The level of connectivity between elements of green infrastructure should be considered as an indicator of the sustainable spatial development goals achievement, in the field of nature conservation and territorial and social cohesion.

Socioeconomic vulnerability and public water arsenic concentrations across the US

Inorganic arsenic is a known human carcinogen and is routinely detected in US community water systems (CWSs). Inequalities in CWS arsenic exist across broad sociodemographic subgroups. Our objective was to evaluate the county-level association between socioeconomic vulnerability and CWS arsenic concentrations across the US. We evaluated previously developed, population-weighted CWS arsenic concentrations (2006–2011) and three socioeconomic domains (the proportion of adults with a high school diploma, median household income, and the Centers for Disease Control and Prevention's overall socioeconomic vulnerability score) for 2,604 conterminous US counties. We used spatial lag models and evaluated the adjusted geometric mean ratio (GMR) of CWS arsenic concentrations per higher socioeconomic domain score corresponding to the interquartile range, and also evaluated flexible quadratic spline models. We also stratified by region and by United States Department of Agriculture Rural-Urban Continuum Codes to assess potential effect measure modification by region and rurality. Associations between socioeconomic vulnerability and CWS arsenic were modified by region and rurality and specific to socioeconomic domain. The fully adjusted GMR (95% CIs) of CWS arsenic per interquartile range higher proportion of adults with a high school education was 0.83 (0.71, 0.98) in the Southwest (corresponding to 17% lower arsenic with higher education), 0.82 (0.71, 0.94) in the Eastern Midwest (18% lower), and 0.65 (0.31, 1.36) in New England (35% lower). Associations between median household income and CWS arsenic were largely null. Higher overall socioeconomic vulnerability was significantly associated with lower CWS arsenic, but only in counties in the Central Midwest and those with total populations less than 20,000. Findings may reflect regional/local differences in both socioeconomic/socio-cultural context and public drinking water regulatory efforts. Across the US, individual domains of socioeconomic vulnerability (especially educational attainment) are more strongly associated with inequalities in CWS arsenic than the complex overall socioeconomic vulnerability index.

Practice patterns of dermatologists who have opted out of Medicare

Practice patterns of dermatologists who have opted out of Medicare

Associations Between Obesity, Rural-Urban Continuum Codes, And Physical Activity Program Preferences Among Breast Cancer Survivors

PURPOSE: Many cancer survivors in rural areas with obesity fail to meet the American College of Sports Medicine physical activity (PA) guidelines. PA promotion programs are needed for these populations. This study examined the associations between obesity, rural-urban continuum (RUCC) codes, and PA program preferences. METHODS: Physically inactive breast cancer survivors (N=222) completed the baseline assessment for a randomized controlled PA trial including surveys to assess PA program preferences (i.e., location, exercise counseling source, exercise counseling delivery, exercise type [walking vs yoga], program type [aerobic vs resistance training], supervised vs unsupervised exercise, individual vs group exercise, flexible vs scheduled, amount willing to pay for exercise program, distance willing to travel, and distance willing to travel if gas costs were covered). Chi-Square analyses using dichotomized variables were conducted. Obesity was defined as body mass index ≥ 30. RUCC codes were classified as metro [RUCC=1 and3] vs non-metro [RUCC=6]. RESULTS: Participants were primarily white (85%), non-Hispanic (98%), and employed (71%) with an average age of 54.4 ± 8.5 years; half (51%) were obese. Most resided in metro areas with <250,000 population (RUCC=3; 73.6%) while the remaining resided in metro areas with >1 million population (RUCC=1; 22%) or nonmetro with 2,500-19,999 population (RUCC=6, 5%). When compared with non-obese, survivors with obesity were more likely to prefer exercise counseling from a personal trainer rather than a cancer exercise specialist, health club exercise specialist, or other cancer survivor (44% of non-obese vs. 57% of obese, p=.03). RUCC was associated with the farthest distance willing to travel (≥16 miles acceptable to 95% of RUCC 1 and 3 vs. 5% of RUCC 6, p<.001) and farthest distance willing to travel if gas costs were covered (≥16 miles acceptable to 42% of RUCC 1 and 3 vs 4% of RUCC 6, p=.027). No other preferences were associated with obesity or RUCC. CONCLUSIONS: Exercise counseling source and distance traveled are preferences associated with obesity or metro vs. nonmetro residency. Future PA programs should consider these factors along with potential reach and access concerns when targeting breast cancer survivors with obesity or living in nonmetro areas.

Demographic and Geographic Variation in Fatal Drug Overdoses in the United States, 1999-2020.

The U.S. drug overdose crisis has been described as a national disaster that has affected all communities. But overdose rates are higher among some subpopulations and in some places than they are in others. This article describes demographic (sex, racial/ethnic, age) and geographic variation in fatal drug overdose rates in the United States from 1999 to 2020. Across most of that timespan, rates were highest among young and middle-age (25-54 years) White and American Indian males and middle-age and older (45+ years) Black males. Rates have been consistently high in Appalachia, but the crisis has spread to several other regions in recent years, and rates are high across the urban-rural continuum. Opioids have been the main contributor, but overdoses involving cocaine and psychostimulants have also increased dramatically in recent years, demonstrating that our problem is bigger than opioids. Evidence suggests that supply-side interventions are unlikely to be effective in reducing overdoses. I argue that the U.S. should invest in policies that address the upstream structural drivers of the crisis.

1340P Trends in access to early phase clinical trials in underserved populations during the COVID-19 pandemic

As the only NCI designated cancer center in the region, it is the mission of University of Kansas Cancer Center (KUCC) to lead efforts to reduce the cancer burden affecting our catchment area. KUCC serves a total population of 4.5 million; 96 counties (78%) and 25% of the population are rural based upon Rural-Urban Continuum Codes (RUCC). Notably, Kansas is a non-Medicaid expansion state and many rural individuals live at or below the poverty level. All but 12 of the 123 counties in KUCC catchment area are primary care Health Professional Shortage Areas by geographic and/or population standards.

Disability and the household context: Findings for the United States from the public Use Microdata Sample of the American Community Survey.

IntroductionBased on questions about impairments and activity limitations, the American Community Survey shows that roughly 13% of the U.S. population is experiencing disability. As most people live in households with other persons, this study explores disability at the household level. Considering the literature on household decision-making, solidarity, and capabilities in disability, this analysis of the household context of disability takes into account residential settings, household composition, and urban–rural differences.MethodThe 2015–2019 ACS Public Use Microdata Sample (PUMS), which shows persons with disability (PwD) and persons without disability (PwoD), also indicates household membership, used here to separately identify PwoD as those living in households with persons with disability (PwoD_HHwD) and those in households without any household member with disability (PwoD_HHwoD). Relationship variables reveal the composition of households with and without disabilities. An adaption of Beale's rural–urban continuum code for counties is used to approximate rural–urban differences with ACS PUMS data.ResultsSolo living is two times as common among persons with disability than among persons without disability, and higher in rural than urban areas. In addition to 43 million PwD, there are another 42 million PwoD_HHwD. Two times as many persons are impacted by disability, either of their own or that of a household member, than shown by an analysis of individual-level disability. For family households, differences in the composition of households with and without disabilities are considerable with much greater complexities in the makeup of families with disability. The presence of multiple generations stands out. Adult sons or daughters without disability play an important role. Modest urban–rural differences exist in the composition of family households with disability, with a greater presence of multigenerational households in large cities.DiscussionThis research reveals the much wider scope of household-level disability than indicated by disability of individuals alone. The greater complexity and multigenerational makeup of households with disability imply intergenerational solidarity, reciprocity, and resource sharing. Household members without disability may add to the capabilities of persons with disabilities. For the sizeable share of PwD living solo, there is concern about their needs being met.

Geographic disparities in cardiovascular mortality among patients with myelodysplastic syndromes: A population-based analysis.

IntroductionClonal hematopoiesis, a precursor to myelodysplastic syndromes (MDS), constitutes a novel cardiovascular disease (CVD) risk factor, causing growing interest in cardiovascular outcomes in MDS. Rurality is associated with increased CVD but studies on cardiovascular geographic disparities in MDS are lacking. MethodsUsing the U.S. Surveillance, Epidemiology, and End Results (SEER) registry, we identified 52,750 MDS patients between 2001 and 2016. Rurality was defined using Rural-Urban Continuum Codes. Cox regression estimated the association of rurality and cardiovascular death. ResultsMDS incidence was equal in urban and rural populations (6.7 per 100,000). Crude probability of cardiovascular death was higher among rural MDS patients. Adjusting for age, sex, race/ethnicity, marital status, insurance, and MDS risk (defined from histology), rural patients had 12% increased risk of CVD death compared to urban patients (HR=1.12, 95%CI 1.03–1.21). HR for CVD death was 1.22 (95%CI 1.01–1.5) in patients from the most rural areas (less than 2500 urban population). Among MDS patients younger than 65 years, rurality was associated with 25% increased risk of CVD death (HR=1.25, 95%CI 1.01–1.59). DiscussionThis population-based analysis suggests that rural residence is linked to higher burden of cardiovascular death in patients with MDS. The disparity is not explained by demographic factors or MDS risk. Interventions targeting CVD may improve outcomes in rural MDS patients.

Accessible Green Spaces? Spatial Disparities in Residential Green Space among People with Disabilities in the United States

This article presents new quantitative results on the distribution of residential green space for people with disabilities in the United States, building on and bridging scholarly research in two distinct domains: one involving approaches that quantify disparities in green space access among racialized minorities and socioeconomically disadvantaged groups, and the other using qualitative methods that demonstrate that most green spaces remain inaccessible and unwelcoming to disabled visitors. Using generalized additive models (GAMs) that controlled for demographic factors and climatological characteristics, we find that residential areas with more green space generally have a higher proportion of disabled residents. The statistical results run counter to expectations from the literature, thus complicating the prevailing narrative and indicating a need for mixed-methods research to examine multiple dimensions of access and environmental justice. Using cluster analysis to assess spatial trends, we detect residential clusters of high disability and low green space and find that they are located in predominantly non-White, urban, and more socioeconomically disadvantaged neighborhoods compared to clusters of high disability and high green space. Cluster analysis results suggest that there are inequities in green space access at the intersection of disability, race, and class, as well as across the urban–rural continuum.

Latent growth trajectories of county-level diabetes prevalence in the United States, 2004–2017, and associations with overall environmental quality

Background:The prevalence of type 2 diabetes (T2D) has increased in the United States, and recent studies suggest that environmental factors contribute to T2D risk. We sought to understand if environmental factors were associated with the rate and magnitude of increase in diabetes prevalence at the county level.Methods:We obtained age-adjusted diabetes prevalence estimates from the CDC for 3,137 US counties from 2004 to 2017. We applied latent growth mixture models to these data to identify classes of counties with similar trends in diabetes prevalence over time, stratified by Rural Urban Continuum Codes (RUCC). We then compared mean values of the US EPA Environmental Quality Index (EQI) 2006–2010, overall and for each of the five domain indices (air, water, land, sociodemographic, and built), with RUCC-specific latent class to examine associations of environmental factors and class of diabetes prevalence trajectory.Results:Overall diabetes prevalence trends between 2004 and 2017 were similar across all RUCC strata. We identified two classes among metropolitan urbanized (RUCC 1) counties; four classes among non-metro urbanized (RUCC 2) counties; and three classes among less urbanized (RUCC 3) and thinly populated (RUCC 4) counties. Associations with overall EQI values and class of diabetes prevalence trends differed by RUCC strata, with the clearest association between poor air EQI and steeper increases in diabetes prevalence among rural counties (RUCC 3 and 4).Conclusions:Similarities in county-level diabetes prevalence trends between 2004 and 2017 were identified for each RUCC strata, although associations with environmental factors varied by rurality.