Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: A population-based cohort study.

BACKGROUND: We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. METHODS AND FINDINGS: In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2-related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value <0.001), mortality (AOR 3.85 [95% CI 3.30 to 4.50], p-value < 0.001), and case fatality (AOR 2.56, 95% CI 2.23 to 2.93, p-value < 0.001) in February to March 2020, but these associations were attenuated and not statistically significant by November 2020 for infection (AOR 1.03 [95% CI 1.00 to 1.07] p-value = 0.05) and mortality (AOR 1.08 [95% CI 0.96 to 1.20], p-value = 0.21) and were reversed for case fatality (AOR 0.86, 95% CI 0.78 to 0.95, p-value = 0.005). American Indian/Alaska Native (AI/AN versus White) race was associated with higher risk of SARS-CoV-2 infection in April and May 2020; this association declined over time and reversed by March 2021 (AOR 0.66 [95% CI 0.51 to 0.85] p-value = 0.004). Hispanic (versus non-Hispanic) ethnicity was associated with higher risk of SARS-CoV-2 infection and mortality during almost every time period, with no evidence of attenuation over time. Urban (versus rural) residence was associated with higher risk of infection (AOR 2.02, [95% CI 1.83 to 2.22], p-value < 0.001), mortality (AOR 2.48 [95% CI 2.08 to 2.96], p-value < 0.001), and case fatality (AOR 2.24, 95% CI 1.93 to 2.60, p-value < 0.001) in February to April 2020, but these associations attenuated over time and reversed by September 2020 (AOR 0.85, 95% CI 0.81 to 0.89, p-value < 0.001 for infection, AOR 0.72, 95% CI 0.62 to 0.83, p-value < 0.001 for mortality and AOR 0.81, 95% CI 0.71 to 0.93, p-value = 0.006 for case fatality). Throughout the observation period, high comorbidity burden, younger age, and obesity were consistently associated with infection, while high comorbidity burden, older age, and male sex were consistently associated with mortality. Limitations of the study include that changes over time in the associations of some risk factors may be affected by changes in the likelihood of testing for SARS-CoV-2 according to those risk factors; also, study results apply directly to VA enrollees who are predominantly male and have comprehensive healthcare and need to be confirmed in other populations. CONCLUSIONS: In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021.

Access to Mechanical Thrombectomy for Ischemic Stroke in the United States.

Background and Purpose: Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy. Methods: We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses. Results: Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%­48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%­35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%­16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25­0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%­28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%­69.9%) of urban patients. For 93.8% (95% CI, 93.6%­94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%­76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity. Conclusions: We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.

The persistence of ancient settlements and urban sustainability.

We propose a dedicated research effort on the determinants of settlement persistence in the ancient world, with the potential to significantly advance the scientific understanding of urban sustainability today. Settlements (cities, towns, villages) are locations with two key attributes: They frame human interactions and activities in space, and they are where people dwell or live. Sustainability, in this case, focuses on the capacity of structures and functions of a settlement system (geography, demography, institutions) to provide for continuity of safe habitation. The 7,000-y-old experience of urbanism, as revealed by archaeology and history, includes many instances of settlements and settlement systems enduring, adapting to, or generating environmental, institutional, and technological changes. The field of urban sustainability lacks a firm scientific foundation for understanding the long durée, relying instead on narratives of collapse informed by limited case studies. We argue for the development of a new interdisciplinary research effort to establish scientific understanding of settlement and settlement system persistence. Such an effort would build upon the many fields that study human settlements to develop new theories and databases from the extensive documentation of ancient and premodern urban systems. A scientific foundation will generate novel insights to advance the field of urban sustainability.

Urban attractors: Discovering patterns in regions of attraction in cities.

Understanding the dynamics by which urban areas attract visitors is important in today's cities that are continuously increasing in population towards higher densities. Identifying services that relate to highly attractive districts is useful to make policies regarding the placement of such places. Thus, we present a framework for classifying districts in cities by their attractiveness to daily commuters and relating Points of Interests (POIs) types to districts' attraction patterns. We used Origin-Destination matrices (ODs) mined from cell phone data that capture the flow of trips between each pair of places in Riyadh, Saudi Arabia. We define the attraction profile for a place based on three main statistical features: The number of visitors a place received, the distribution of distance traveled by visitors on the road network, and the spatial spread of locations from where trips started. We used a hierarchical clustering algorithm to classify all places in the city by their features of attraction. We discovered three main types of Urban Attractors in Riyadh during the morning period: Global, which are significant places in the city, Downtown, which contains the central business district, and Residential attractors. In addition, we uncovered what makes districts possess certain attraction patterns. We used a statistical significance testing approach to quantify the relationship between Points of Interests (POIs) types (services) and the patterns of Urban Attractors detected.

The impact of occupational structures on ethnic and gendered employment gaps: An event history analysis using social security register data.

Ethnic and gendered employment gaps are mainly explained by individual characteristics, while less attention is paid to occupational structures. Drawing on administrative data, this article analyses the impact of occupational characteristics on top of individual attributes in the urban labour market of Vienna. Both set of variables can explain observed employment gaps to a large extent, but persistent gaps remain, in particular among females. The article's main finding is that the occupational structure appears to have gendered effects. While men tend to benefit from ethnic segregation, women face difficulties when looking for jobs with high shares of immigrant workers. Looking for jobs in occupations that recruit from relatively few educational backgrounds (credentials) is beneficial for both sexes at the outset unemployment, but among females this competitive advantage diminishes over time. The article concludes by discussing potential strategies to avoid the traps of occupational segregation.

The double burden of malnutrition in India: Trends and inequalities (2006-2016).

Rapid urban expansion has important health implications. This study examines trends and inequalities in undernutrition and overnutrition by gender, residence (rural, urban slum, urban non-slum), and wealth among children and adults in India. We used National Family Health Survey data from 2006 and 2016 (n = 311,182 children 0-5y and 972,192 adults 15-54y in total). We calculated differences, slope index of inequality (SII) and concentration index to examine changes over time and inequalities in outcomes by gender, residence, and wealth quintile. Between 2006 and 2016, child stunting prevalence dropped from 48% to 38%, with no gender differences in trends, whereas child overweight/obesity remained at ~7-8%. In both years, stunting prevalence was higher in rural and urban slum households compared to urban non-slum households. Within-residence, wealth inequalities were large for stunting (SII: -33 to -19 percentage points, pp) and declined over time only in urban non-slum households. Among adults, underweight prevalence decreased by ~13 pp but overweight/obesity doubled (10% to 21%) between 2006 and 2016. Rises in overweight/obesity among women were greater in rural and urban slum than urban non-slum households. Within-residence, wealth inequalities were large for both underweight (SII -35 to -12pp) and overweight/obesity (+16 to +29pp) for adults, with the former being more concentrated among poorer households and the latter among wealthier households. In conclusion, India experienced a rapid decline in child and adult undernutrition between 2006 and 2016 across genders and areas of residence. Of great concern, however, is the doubling of adult overweight/obesity in all areas during this period and the rise in wealth inequalities in both rural and urban slum households. With the second largest urban population globally, India needs to aggressively tackle the multiple burdens of malnutrition, especially among rural and urban slum households and develop actions to maintain trends in undernutrition reduction without exacerbating the rapidly rising problems of overweight/obesity.

Identification of urban land use efficiency by indicator-SDG 11.3.1.

Inefficiency in urban land use is one of the problems caused by rapid urbanization. The UN Sustainable Development Goals (SDGs) indicator 11.3.1 is designed to test urban land use efficiency. This study employed geospatial and statistical data to compute land use efficiencies from 1990 to 2015 with five 5-year and ten 15-year intervals in Wukang, center of Deqing County, China. A flowchart was designed to extract the built-up lands from multiple data sources. The produced built-up lands were demonstrated to provide good accuracy by constructing an error matrix between the extracted and manually interpreted built-up lands as classified and reference images, respectively. By using the model provided by UN metadata to calculate SDG 11.3.1, the land use efficiencies from 1990 to 2015 were identified in Wukang. Our results indicate that the land use efficiency in Deqing County center is lower than the average of cities around the world, primarily because our in-situ study focused on a county center with larger rural regions than urban areas. Over the long term, urban land use becomes denser as the population grows, which will have a positive impact on the sustainability of urban development. This work is helpful for the local government to balance urban land consumption and population growth.

Racial and gender inequities in the implementation of a cannabis criminal justice diversion program in a large and diverse metropolitan county of the USA.

BACKGROUND: Diversion programs are considered alternatives to the arrest and incarceration of non-violent drug offenders, including those found in possession of smaller amounts of cannabis in states with prohibitive laws. Despite the progressive nature of such programs, the inability to complete diversion program requirements can often result in greater involvement with the criminal justice system than traditional case adjudication. Few studies have evaluated racial group differences in cannabis diversion program completion. METHODS: The current study examined a sample of 8323 adult participants in Harris County, Texas' Marijuana Misdemeanor Diversion Program (MMDP) between March 2017 and July 2019. Gender, age, and race/ethnicity were examined as predictors of program completion and time to completion using Chi square, Kruskal Wallis tests, and Cox proportional hazard regression models. RESULTS: Both males and African Americans were over-represented (80 % and 50 %, respectively) among participants of Harris County's MMDP. African American (HR = 0.782, 95 % CI [.735-.832], p < .001) and Latino American MMDP participants (HR = .822, 95 % CI [.720-.937], p = .003) had significantly lower odds of MMDP completion and a longer interval to program completion as compared to non-Latino White participants. CONCLUSIONS: The current study identified racial/ethnic and gender disparities in a large county's cannabis diversion program. These findings may be related to law enforcement disparities which disproportionately target males and people of color. Findings may serve to inform the continued reform of the criminal justice system, particularly laws relating to cannabis.

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study.

BACKGROUND: Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000-100,000 women work in the sex industry. However, little is known about their drug use behaviors. OBJECTIVE: To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic. METHODS: Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use. RESULTS: Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older. CONCLUSIONS: Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.

HIV testing and treatment coverage achieved after 4 years across 14 urban and peri-urban communities in Zambia and South Africa: An analysis of findings from the HPTN 071 (PopART) trial.

BACKGROUND: In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set the 90-90-90 targets: that 90% of people living with HIV know their HIV status, that 90% of those who know their HIV-positive status are on antiretroviral therapy (ART), and that 90% of those on treatment are virally suppressed. The aim was to reach these targets by 2020. We assessed the feasibility of achieving the first two targets, and the corresponding 81% ART coverage target, as part of the HIV Prevention Trials Network (HPTN) 071 Population Effects of Antiretroviral Therapy to Reduce HIV Transmission (PopART) community-randomized trial. METHODS AND FINDINGS: The study population was individuals aged ≥15 years living in 14 urban and peri-urban "PopART intervention" communities in Zambia and South Africa (SA), with a total population of approximately 600,000 and approximately 15% adult HIV prevalence. Community HIV care providers (CHiPs) delivered the PopART intervention during 2014-2017. This was a combination HIV prevention package including universal home-based HIV testing, referral of HIV-positive individuals to government HIV clinic services that offered universal ART (Arm A) or ART according to national guidelines (Arm B), and revisits to HIV-positive individuals to support linkage to HIV care and retention on ART. The intervention was delivered in 3 "rounds," each about 15 months long, during which CHiPs visited all households and aimed to contact all individuals aged ≥15 years at least once. In Arm A in Round 3 (R3), 67% (41,332/61,402) of men and 86% (56,345/65,896) of women in Zambia and 56% (17,813/32,095) of men and 71% (24,461/34,514) of women in SA participated in the intervention, among 193,907 residents aged ≥15 years. Following participation, HIV status was known by 90% of men and women in Zambia and by 78% of men and 85% of women in SA. The median time from CHiP referral of HIV-positive individuals to ART initiation was approximately 3 months. By the end of R3, an estimated 95% of HIV-positive women and 85% of HIV-positive men knew their HIV status, and among these individuals, approximately 90% of women and approximately 85% of men were on ART. ART coverage among all HIV-positive individuals was approximately 85% in women and approximately 75% in men, up from about 45% at the start of the study. ART coverage was lowest among men aged 18 to 34 and women aged 15 to 24 years, and among mobile individuals/in-migrants. Findings from Arm B were similar. The main limitations to our study were that estimates of testing and treatment coverage among men relied on considerable extrapolation because, in each round, approximately one-third of men did not participate in the PopART intervention; that our findings are for a service delivery model that was relatively intensive; and that we did not have comparable data from the 7 "standard-of-care" (Arm C) communities. CONCLUSIONS: Our study showed that very high HIV testing and treatment coverage can be achieved through persistent delivery of universal testing, facilitated linkage to HIV care, and universal treatment services. The ART coverage target of 81% was achieved overall, after 4 years of delivery of the PopART intervention, though important gaps remained among men and young people. Our findings are consistent with previously reported findings from southern and east Africa, extending their generalisability to urban settings with high rates of in-migration and mobility and to Zambia and SA. TRIAL REGISTRATION: ClinicalTrials.gov NCT01900977.

Nonprofit Hospitals' Response to the Opioid Epidemic in Urban Communities: A Content Analysis of Hospitals' Community Health Needs Assessments and Implementation Strategies.

CONTEXT: Addressing the opioid epidemic requires a coordinated community response; yet, the role that nonprofit hospitals play in these efforts has not been systematically examined. OBJECTIVE: To explore hospital-initiated strategies to address opioid use in urban communities most affected by the opioid epidemic. DESIGN: We conducted content analysis of publicly available community health needs assessments (CHNAs) and accompanying implementation strategies of 140 nonprofit hospitals. We employed a qualitative approach using open coding methods to explore the extent to which hospitals identified opioid use as a community health need and engaged in interventions to address opioid use in their communities. We also conducted bivariate analysis to compare organizational and community characteristics of hospitals that did and did not engage in strategies to address opioid use. SETTING: One hundred forty nonprofit hospitals in urban areas with high opioid death rates across 25 states. RESULTS: Almost 70% of CHNAs identified opioid use as a community health need, and 63% of implementation strategies included at least 1 hospital-initiated activity to address this need. More than 90% of these implementation strategies involved providing additional capacity for and access to treatment. Bivariate analysis showed that hospitals that engaged in activities to address opioid use did not differ meaningfully from hospitals that did not engage in such activities, with 2 exceptions. Hospitals that relied on consultants to prepare the CHNA were more likely to engage in activities to address opioid use as were hospitals located in Medicaid expansion states. CONCLUSIONS: Nonprofit hospitals are taking action to address the opioid epidemic in their communities, most commonly by providing additional treatment capacity for patients with opioid use. While an important contribution, hospitals need incentives to develop a more comprehensive response to the opioid epidemic that extends beyond medical care to include the social and economic determinants of this crisis.

Small towns shrinkage in the Jilin Province: A comparison between China and developed countries.

Urban shrinkage is currently spreading at global level. At the same time, the scale of urban shrinkage is not limited to urban agglomerations, metropolitan areas, or big cities, but begins to expand to a vast number of small towns. Over the years, the characteristics, models, and mechanisms of shrinkage in large cities have attracted the attention of scholars; however, the problem of shrinkage in small towns has not been fully discussed. In China, small towns are located at the margins of cities and are the first part of the countryside; hence, they are the link and the bridge between urban and rural areas, and a space carrier to solve the diseases of big cities and for rural rejuvenation as a whole. However, in the process of rapid urbanization, some small towns have experienced urban shrinkage, mainly through a decline in township enterprises and the deterioration of the living environment, which has restricted their role in coordinating the spatial support of urban and rural development. Therefore, a correct understanding of the shrinkage of small towns has considerable theoretical and practical guiding significance. We focused on the towns of the Jilin Province as the research unit, and combined township population, economy, land use, and employment indices to establish an urban shrinkage index, identifying the status, spatial distribution, and influencing factors of small towns shrinkage in the Jilin Province. Moreover, we analyzed the similarities and differences of small towns shrinkage between the Jilin Province and developed countries. The results show that small towns shrinkage in the Jilin Province shares similar characteristics with developed countries, as well as important differences in aspects such as population migration, low-level industrial structure, and administrative division adjustments.

Prevalence and determinants of caesarean section in South and South-East Asian women.

BACKGROUND: Caesarean section is considered a relatively preferable and safe method of delivery as compared to normal delivery. Since the last decade, its prevalence has increased in both developed and developing countries. In the context of developing countries viz., South Asia (the highest populated region) and South-East Asia (the third-highest populated region), where a significant proportion of home deliveries were reported,however, the preference for, caesarean delivery and its associated factors are not well understood. OBJECTIVE: To study the caesarean delivery in the South and South-East Asian countries and to determine the factors associated with the preference for caesarean delivery. METHODOLOGY: Demographic and Health Survey Data on from ever-married women of nine developing countries of South and South-East Asia viz., Vietnam, India, Maldives, Timor-Leste, Nepal, Indonesia, Pakistan, Bangladesh, and Cambodia have been considered. Both bivariate and binary logistic regression models were used to estimate the propensity of a woman undergoing for caesarean delivery and to assess the influence of maternal socioeconomic characteristics towards the preference for caesarean delivery. RESULTS: Obtained results have shown an inclination of caesarean delivery among urban than rural women and are quite conspicuous, but is found to be underestimated mostly among rural women. Caesarean delivery in general is mostly predisposed among women whose baby sizes are either very large or smaller than average, have a higher level of education and place of delivery is private medical institutions. The logistic regression also revealed the influence of maternal socioeconomic characteristics towards the preference for caesarean delivery. Based on nine South and South-East Asian countries an overall C-section prevalence of 13%, but based on institutional births its increase to 19%. The forest plot demonstrated that a significant inclination of C-section among urban than rural regions. In Meta-Analysis, very high and significant heterogeneity among countries is observed, but confirms that in terms of prevalence of C-section all of the countries follow independent pattern. CONCLUSION: Study of seven urban and four rural regions of nine South and South- East Asian countries showed, a significant inclination towards the caesarean delivery above the more recent outdated WHO recommended an optimal range of 10-15%and are associated maternal socioeconomic characteristics. In order to control unwanted caesarean delivery, the government needs to develop better healthcare infrastructure and along with more antenatal care related schemes to reduce the risks associated with increased caesarean delivery.

The role of personal factors in attitudes toward the adoption of new consumption behaviors in developing food systems.

Through dual-period surveys in urban China, administered in the years 1996 and 2013, this study investigates changes in the relationship among personal factors and the attitudes toward the adoption of new food consumption patterns as food systems develop. A structural equation model (SEM) is used to measure the association among three personal factors (traditionalism, do-it-yourself [DIY] propensity, and time scarcity) and attitudes toward three new food consumption behaviors (use of processed food, eating out, and convenience shopping). The results reveal complex relationships between personal factors and attitudes toward the adoption of new food shopping behaviors, indicating that supply-side models of retailing development are insufficient to adequately predict changes in food systems.

Rural-Urban Differences in Adverse Childhood Experiences Across a National Sample of Children.

PURPOSE: The purpose of this study was to examine the prevalence of adverse childhood experiences (ACEs) exposure in 34 states and the District of Columbia, and whether exposure differs between rural and urban residents. METHODS: This cross-sectional study used data from the 2016 National Survey of Children's Health (NSCH), restricted to states in which rural versus urban residence was indicated in the public use data (n = 25,977 respondents). Bivariate analyses were used to estimate unadjusted associations. Multivariable regression models were run to examine the association between residence (rural or urban) and ACE counts of 4 or more. FINDINGS: Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined: parental separation/divorce, parental death, household incarceration, household violence, household mental illness, household substance abuse, and economic hardship. In adjusted analysis, there was no significant difference for rural children compared to urban children. The odds of 4 or more ACEs decrease as poverty levels decline, with children residing 0%-99% below the federal poverty line more likely to have reported 4 or more ACEs, compared to children residing 400% or above the federal poverty line (aOR 4.02; CI: 2.65-6.11). CONCLUSIONS: Our findings suggest that poverty is a key policy lever that may mitigate the burden of ACE exposure. The findings of this study may be instructive for policymakers and program planners as they develop interventions to stop, reduce, or mitigate ACE exposure and the long-term impact of ACEs among children in rural America.

Rural-Urban Differences in Access to Primary Care: Beyond the Usual Source of Care Provider.

INTRODUCTION: In the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Therefore, it is important to understand rural-urban differences in access to medical care. This study compared the percentage of individuals with a usual source of care and characteristics of usual source of care providers across 3 urban-rural categories. METHODS: This study identified 51,920 adults from the 2014-2016 Medical Expenditure Panel Survey and estimated the percentage with a usual source of care across the rural-urban categories. Then, differences in a variety of provider characteristics were examined. Estimates were weighted to be representative of the U.S. non-institutionalized population and adjusted for age, race/ethnicity, self-rated health, and presence of chronic conditions. Analysis was conducted in 2018 and 2019. RESULTS: Compared with metropolitan county residents, residents of the most rural counties were 7 percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 18 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%). CONCLUSIONS: Rural-urban differences in access to care are complex; there is a rural disadvantage on some dimensions of access but not others. To understand rural-urban disparities in healthcare access, research should move beyond the usual source of care provider as an overall indicator and instead investigate disparities using multiple indicators of access based on theoretically distinct domains.

Association between community greenness and obesity in urban-dwelling Chinese adults.

Living in greener places may protect against obesity, but epidemiological evidence is inconsistent and mainly comes from developed nations. We aimed to investigate the association between greenness and obesity in Chinese adults and to assess air pollution and physical activity as mediators of the association. We recruited 24,845 adults from the 33 Communities Chinese Health Study in 2009. Central and peripheral obesity were defined by waist circumference (WC) and body mass index (BMI), respectively, based on international obesity standards. The Normalized Difference Vegetation Index (NDVI) was used to quantify community greenness. Two-level logistic and generalized linear mixed regression models were used to evaluate the association between NDVI and obesity, and a conditional mediation analysis was used also performed. In the adjusted models, an interquartile range increase in NDVI500-m was significantly associated with lower odds of peripheral 0.80 (95% confidence interval [CI]: 0.74-0.87) and central obesity 0.88 (95% CI: 0.83-0.93). Higher NDVI values were also significantly associated with lower BMI. Age, gender, and household income significantly modified associations between greenness and obesity, with stronger associations among women, older participants, and participants with lower household incomes. Air pollution mediated 2.1-20.8% of the greenness-obesity associations, but no mediating effects were observed for physical activity. In summary, higher community greenness level was associated with lower odds of central and peripheral obesity, especially among women, older participants, and those with lower household incomes. These associations were partially mediated by air pollutants. Future well-designed longitudinal studies are needed to confirm our findings.