Geographic Variation, Economic Activity, and Labor Market Characteristics in Trajectories of Suicide in the United States, 2008-2020.

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

State COVID-19 Policies and Drug Overdose Mortality Among Working-Age Adults in the United States, 2020.

Objectives. To identify relationships between US states' COVID-19 in-person activity limitation and economic support policies and drug overdose deaths among working-age adults in 2020. Methods. We used county-level data on 140 435 drug overdoses among adults aged 25 to 64 years during January 2019 to December 2020 from the National Vital Statistics System and data on states' COVID-19 policies from the Oxford COVID-19 Government Response Tracker to assess US trends in overdose deaths by sex in 3138 counties. Results. Policies limiting in-person activities significantly increased, whereas economic support policies significantly decreased, overdose rates. A 1-unit increase in policies restricting activities predicted a 15% average monthly increase in overdose rates for men (incident rate ratio [IRR] = 1.15; 95% confidence interval [CI] = 1.09, 1.20) and a 14% increase for women (IRR = 1.14; 95% CI = 1.09, 1.20). A 1-unit increase in economic support policies predicted a 3% average monthly decrease for men (IRR = 0.97; 95% CI = 0.95, 1.00) and a 4% decrease for women (IRR = 0.96; 95% CI = 0.93, 0.99). All states' policy combinations are predicted to have increased drug-poisoning mortality. Conclusions. The economic supports that states enacted were insufficient to fully mitigate the adverse relationship between activity limitations and drug overdoses. (Am J Public Health. 2024;114(7):714-722. https://doi.org/10.2105/AJPH.2024.307621).

Self-Rated Physical Health Among Working-Aged Adults Along the Rural-Urban Continuum - United States, 2021.

Poor self-rated physical health is strongly associated with morbidity and premature mortality (1,2). Studies that are now a decade old report worse self-rated health among rural than among urban residents (3,4). Whether the rural disadvantage persists in 2021 is uncertain and the contributing factors to contemporary rural-urban variations in self-rated health are not known. Rural America is diverse by population size and adjacency to metropolitan areas, and rural populations vary demographically and socioeconomically. This analysis used data from the National Well-being Survey (NWS), a national sample of approximately 4,000 U.S. working-aged adults conducted during February and March 2021 to examine differences in self-rated physical health among residents of large urban; medium/small urban; metro-adjacent rural; and remote rural counties. Residents of medium/small urban, metro-adjacent rural, and remote rural counties had significantly higher probabilities of reporting fair/poor self-rated physical health than their large urban county peers. There were no significant differences by sex or race/ethnicity in self-rated physical health. Individual-level socioeconomic resources (including higher educational attainment, higher household income, and higher probability of employment) contributed to the advantage among residents of large urban counties. Although there is no single solution to reducing rural-urban health disparities, these findings suggest that reducing socioeconomic disparities is essential.

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.

Effects of US state preemption laws on infant mortality.

Studies show that raising the minimum wage in a US state above the federal minimum wage can reduce infant mortality rates in those states. Some states have raised their minimum wage in recent decades, while many others did not, and have prohibited local authorities from doing so by enacting preemption laws. This study investigates how the recent emergence of state preemption laws that remove local authority to raise the minimum wage has affected infant mortality rates. Using county- and state- level data spanning 2001 through 2018, this study models infant mortality rates as a function of minimum wage levels, controlling for confounders. The estimated model, combined with information on the timing, location, and level of preempted minimum wages, is then used to estimate the number of infant deaths that occurred in 2018 that could be attributed to state preemption of local minimum wage increases. In the 9 largest (pop. > 250,000) metro counties most directly affected by state preemption, we estimate that in 2018, 25 infant deaths were attributable to preemption. This equates to a 5.4% reduction in these counties' infant mortality rate. When considering all large metro counties in preemption states, as many as 605 infant deaths could be attributed to preemption. State preemption laws that remove local authority to enact health-promoting legislation, such as minimum wage increases, are a significant threat to population health. The growing tide of these laws, particularly since 2010, may be contributing to recent troubling trends in US life expectancy.

Rural-Urban Variation in COVID-19 Experiences and Impacts among U.S. Working-Age Adults.

This study investigates rural-urban differences in COVID-19 in terms of its impacts on the physical and mental health, social relationships, employment, and financial hardship of U.S. working-age adults (18-64). I use data from the National Wellbeing Survey collected in February and March 2021 (N=3,933). Most respondents (58 percent) reported that COVID-19 has had a negative impact on their lives. Residents of rural counties adjacent to metro areas reported the worst outcomes: they were more likely than residents of large urban counties to report positive tests for coronavirus; to live with someone who tested positive or have a close friend or family member outside of the household test positive; to have a close friend or family member hospitalized; to seek treatment for anxiety or depression; to be late paying rent, mortgage, and other bills; to not be able to afford groceries or other necessities; and to get a loan from family or friends. Recovery policies must consider geographic variation in COVID-19 vulnerability and impacts.

Rural Population Health and Aging: Toward a Multilevel and Multidimensional Research Agenda for the 2020s.

The unique health and aging challenges of rural populations often go unnoticed. In fact, the rural United States is home to disproportionate shares of older and sicker people, there are large and growing rural-urban and within-rural mortality disparities, many rural communities are in population decline, and rural racial/ethnic diversity is increasing.Yet rural communities are not monolithic, and although some rural places are characterized by declining health, others have seen large improvements in population health. We draw on these realities to call for new research in five areas.First, research is needed to better describe health disparities between rural and urban areas and, because rural places are not monolithic, across rural America. Second, research is needed on how trends in rural population health and aging are affecting rural communities. Third, research is needed on the ways in which economic well-being and livelihood strategies interact with rural health and aging. Fourth, we need to better understand the health implications of the physical and social isolation characterizing many rural communities. Finally, we argue for new research on the implications of local natural environments and climate change for rural population health and aging.

Using Census Data to Understand County-Level Differences in Overall Drug Mortality and Opioid-Related Mortality by Opioid Type.

Objectives. To examine associations of county-level demographic, socioeconomic, and labor market characteristics on overall drug mortality rates and specific classes of opioid mortality. Methods. We used National Vital Statistics System mortality data (2002-2004 and 2014-2016) and county-level US Census data. We examined associations between several census variables and drug deaths for 2014 to 2016. We then identified specific classes of counties characterized by different levels and rates of growth in mortality from specific opioid types between 2002 to 2004 and 2014 to 2016. We ran multivariate and multivariable regression models to predict probabilities of membership in each "opioid mortality class" on the basis of county-level census measures. Results. Drug mortality rates overall are higher in counties characterized by more economic disadvantage, more blue-collar and service employment, and higher opioid-prescribing rates. High rates of prescription opioid overdoses and overdoses involving both prescription and synthetic opioids cluster in more economically disadvantaged counties with larger concentrations of service industry workers. High heroin and "syndemic" opioid mortality counties (high rates across all major opioid types) are more urban, have larger concentrations of professional workers, and are less economically disadvantaged. Syndemic opioid counties also have greater concentrations of blue-collar workers. Conclusions. Census data are essential tools for understanding the importance of place-level characteristics on opioid mortality. Public Health Implications. National opioid policy strategies cannot be assumed universally applicable. In addition to national policies to combat the opioid and larger drug crises, emphasis should be on developing locally and regionally tailored interventions, with attention to place-based structural economic and social characteristics.

"You Never Know What You're Getting": Opioid Users' Perceptions of Fentanyl in Southwest Pennsylvania.

BACKGROUND: Urban areas in the United States have experienced a dramatic surge in fentanyl overdose deaths since 2014, a trend affecting both larger and smaller metropolitan areas. Encompassing only 1.2 million residents, Allegheny County, Pennsylvania, nevertheless saw 412 fentanyl-involved deaths in 2016, a number surpassed only by New York City and Cook County (Chicago), Illinois. OBJECTIVES: This article seeks to describe opioid users' perceptions of fentanyl in Allegheny and three adjacent counties; it further considers how the drug's emergence shapes some users' market behaviors and consumption practices. METHODS: This article reports on qualitative interview data (N = 30) collected as part of a larger, multi-phase, mixed methods study (N = 125) among individuals reporting past-year prescription opioid misuse or heroin use in four southwest Pennsylvania Counties. RESULTS: Most interviewees reported past-year suspected exposure to fentanyl, and many reported suffering or seeing suspected fentanyl overdoses. Where roughly one-third reported strategies for avoiding fentanyl, a small group of interviewees identified advantages to fentanyl, while still acknowledging its associated risks. Conclusions/Importance: Given users' diverse opinions around fentanyl, the distribution of fentanyl test strips may represent an effective response to the current crisis.

Associations between demographic characteristics and physical activity practices in Nevada schools.

Schools are important settings for not only providing and promoting children's physical activity (PA) but also for reducing PA disparities. We investigated associations between school-level demographic characteristics (racial/ethnic and socioeconomic composition, urban-rural status, and student-to-teacher ratio) and 16 PA-promoting practices in 347 Nevada public elementary, middle, and high schools in 2014. We found that low-cost and easy-to-implement practices are most prevalent. There is relative demographic equity in ten of 16 PA practices and significant differences in six PA practices in Nevada schools. Schools with comparatively larger percentages of Black students are the most disadvantaged, as they have the fewest PA-supportive practices in place. Higher percent black was associated with lower odds of providing classroom activity breaks (AOR=0.632, 95% CI=0.453-0.881) and bike racks (AOR=0.60, 95% CI=0.362-0.996), greater odds of withholding recess/PE for disciplinary reasons (AOR=1.377, 95% CI=1.006-1.885), and lower odds of having recess supervisors who are trained to promote PA (AOR=0.583, 95% CI=0.374-0.909). Schools with greater percentages of Hispanic students have lower odds of providing before-school PA programs (AOR=0.867, 95% CI=0.761-0.987), whereas schools with greater percentages of low-SES students have greater odds of providing after-school PA programs (AOR=1.135, 95% CI=1.016-1.268). Higher student-to-teacher ratio was also associated with greater odds of providing after-school PA programs (AOR=1.135, 95% CI=1.016-1.268). Urban-rural status was unrelated to all PA practices.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access.

OBJECTIVES: This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination. METHODS: Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination. RESULTS: Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls. CONCLUSIONS: Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

The Great Recession and America's Geography of Unemployment.

BACKGROUND: The Great Recession of 2007-2009 was the most severe and lengthy economic crisis in the U.S. since the Great Depression. The impacts on the population were multi-dimensional, but operated largely through local labor markets. OBJECTIVE: To examine differences in recession-related changes in county unemployment rates and assess how population and place characteristics shaped these patterns. METHODS: We calculate and decompose Theil Indexes to describe recession-related changes in the distribution of unemployment rates between counties and states. We use exploratory spatial statistics to identify geographic clusters of counties that experienced similar changes in unemployment. We use spatial regression to evaluate associations between county-level recession impacts on unemployment and demographic composition, industrial structure, and state context. RESULTS: The recession was associated with increased inequality between county labor markets within states, but declining between-state differences. Counties that experienced disproportionate recession-related increases in unemployment were spatially clustered and characterized by large shares of historically disadvantaged racial and ethnic minority populations, low educational attainment, and heavy reliance on pro-cyclical industries. Associations between these sources of vulnerability were partially explained by unobserved state-level factors. CONCLUSIONS: The local consequences of macroeconomic trends are associated with county population characteristics, as well as the structural contexts and policy environments in which they are embedded. The recession placed upward pressure on within-state inequality between local labor market conditions. CONTRIBUTION: To present new estimates of the recession's impact on local labor markets, quantify how heterogeneous impacts affected the distribution of unemployment prevalence, and identify county characteristics associated with disproportionately large recession-related increases in unemployment.

Distress in the Desert: Neighborhood Disorder, Resident Satisfaction, and Quality of Life during the Las Vegas Foreclosure Crisis.

Using surveys collected from a sample of households nested within 'naturally occurring' neighborhoods in Las Vegas, NV during the 2007-2009 economic recession, this study examines the associations between real and perceived measures of neighborhood distress (foreclosure rate, physical decay, crime) and residents' reports of neighborhood quality of life and neighborhood satisfaction. Consistent with social disorganization theory, both real and perceived measures of neighborhood disorder were negatively associated with quality of life and neighborhood satisfaction. Residents' perceptions of neighborliness partially acted as a buffer against the effects of neighborhood distress, including housing foreclosures, on quality of life and neighborhood satisfaction.

Long Term Physical Health Consequences of Adverse Childhood Experiences.

This study examined associations between adverse childhood family experiences and adult physical health using data from 52,250 US adults aged 18-64 from the 2009-2012 Behavioral Risk Factor Surveillance System (BRFSS). We found that experiencing childhood physical, verbal, or sexual abuse, witnessing parental domestic violence, experiencing parental divorce, and living with someone who was depressed, abused drugs or alcohol, or who had been incarcerated were associated with one or more of the following health outcomes: self-rated health, functional limitations, diabetes, and heart attack. Adult socioeconomic status and poor mental health and health behaviors significantly mediated several of these associations. The results of this study highlight the importance of family-based adverse childhood experiences on adult health outcomes and suggest that adult SES and stress-related coping behaviors may be crucial links between trauma in the childhood home and adult health.

Correlates of state enactment of elementary school physical education laws.

OBJECTIVE: To describe variation in U.S. state elementary school physical education (PE) policies and to assess associations between state PE policy enactment and education funding, academic achievement, sociodemographic disadvantage, and political characteristics. METHODS: U.S. state laws regarding school PE time, staffing, curriculum, fitness assessment, and moderate-to-vigorous physical activity (MVPA) in 2012 were classified as strong/specific, weak/nonspecific, or none based on codified law ratings within the Classification of Laws Associated with School Students (C.L.A.S.S.). Laws were merged with state-level data from multiple sources. Logistic regression was used to determine associations between state characteristics and PE laws (N=51). RESULTS: Laws with specific PE and MVPA time requirements and evidence-based curriculum standards were more likely in states with low academic performance and in states with sociodemographically disadvantaged populations. School day length was positively associated with enacting a PE curriculum that referenced evidence-based standards. School funding and political characteristics were not associated with PE laws. CONCLUSIONS: Limited time and high-stake testing requirements force schools to prioritize academic programs, posing barriers to state passage of specific PE laws. To facilitate PE policy enactment, it may be necessary to provide evidence on how PE policies can be implemented within existing time and staffing structures.

Exploring the relationship between treatment satisfaction, perceived improvements in functioning and well-being and gambling harm reduction among clients of pathological gambling treatment programs.

The objective of this study was to evaluate the relationship between treatment service quality, perceived improvement in social, functional, and material well-being and reduction in gambling behaviors among clients of Nevada state-funded pathological gambling treatment programs. Utilizing survey data from 361 clients from 2009 to 2010, analyses revealed that client satisfaction with treatment services is positively associated with perceived improvements in social, functional, and material well-being, abstinence from gambling, reduction in gambling thoughts and reduction in problems associated with gambling, even after controlling for various respondent characteristics. These findings can be useful to treatment program staff in managing program development and allocating resources.

Neighborhood Reputation and Resident Sentiment in the Wake of the Las Vegas Foreclosure Crisis.

This study examines how two major components of a neighborhood's reputation-perceived disorder and collective efficacy-shape individuals' sentiments toward their neighborhoods during the foreclosure crisis triggered by the Great Recession. Of central interest are whether neighborhood reputations are durable in the face of a crisis (neighborhood resiliency hypothesis) or whether neighborhood reputations wane during times of duress (foreclosure crisis hypothesis). Geo-coded individual-level data from the Las Vegas Metropolitan Area Social Survey merged with data on census tract foreclosure rates are used to address this question. The results provide qualified support for both perspectives. In support of the neighborhood resiliency hypothesis, collective efficacy is positively associated with how residents feel about the quality of their neighborhoods, and this relationship is unaltered by foreclosure rates. In support of the foreclosure crisis hypothesis, foreclosure rates mediate the effects of neighborhood disorder on resident sentiment. The implications of these findings for community resiliency are discussed.

Watchful, skeptics, and system distrusters: Characteristics associated with different types of COVID-19 vaccine hesitancy among U.S. working-age adults.

COVID-19 vaccine hesitancy is complex, with adults identifying various reasons for not getting vaccinated. Using data from the 2022 National Wellbeing Survey on 7612 U.S. adults aged 18-64, we identified how age, race/ethnicity, sex, marital status, education, income, employment status, partisanship, and metropolitan status are associated with COVID-19 vaccination status and three non-mutually exclusive types of vaccine hesitancy: 1) watchful, concerned about vaccine side effects and efficacy; 2) skeptics, distrust the vaccine, and 3) system distrusters, distrust government. A third of respondents overall (N = 2643) had not received at least one dose at the time of the survey. Among respondents who were not vaccinated, 67 % are classified as watchful, 53 % are skeptics, and 32 % are system distrusters. Results from logistic regression show that concerns about side effects and safety (watchfulness) appear to be major drivers for not getting vaccinated among females and among non-Hispanic Black and unmarried adults, whereas skepticism and distrust appear to be more important barriers among ages 25-44. All three types of hesitancy appear to be important contributors to lower vaccination uptake among low-income, low-education, and unemployed adults, and among individuals who voted for Donald Trump in the 2020 election (with skepticism and distrust being most endorsed by this group). Findings suggest that universal messaging and intervention strategies are unlikely to be effective in reducing vaccine hesitancy. Different messages, messengers, and tactics must be used with different groups.

Geographically specific associations between county-level socioeconomic and household distress and mortality from drug poisoning, suicide, alcohol, and homicide among working-age adults in the United States.

Background: Mortality rates from drug poisoning, suicide, alcohol, and homicide vary significantly across the United States. This study explores localized relationships (i.e., geographically specific associations) between county-level economic and household distress and mortality rates from these causes among working-age adults (25-64). Methods: Mortality data were from the National Vital Statistics System for 2014-2019. County-level socioeconomic distress (poverty, employment, income, education, disability, insurance) and household distress (single-parent, no vehicle, crowded housing, renter occupied) were from the 2009-2013 American Community Survey. We conducted Ordinary Least Squares (OLS) regression to estimate average associations and Geographically Weighted Regression (GWR) to estimate localized spatial associations between county-level distress and working-age mortality. Results: In terms of national average associations, OLS results indicate that a one standard deviation increase in socioeconomic distress was associated with an average of 6.1 additional drug poisoning deaths, 3.0 suicides, 2.1 alcohol-induced deaths, and 2.0 homicides per 100,000 population. A one standard deviation increase in household distress was associated with an average of 1.4 additional drug poisonings, 4.7 alcohol-induced deaths, and 1.1 homicides per 100,000 population. However, the GWR results showed that these associations vary substantially across the U.S., with socioeconomic and household distress associated with significantly higher mortality rates in some parts of the U.S than others, significantly lower rates in other parts of the U.S., and no significant associations in others. There were also some areas where distress overlapped to influence multiple causes of death, in a type of compounded disadvantage. Conclusions: Socioeconomic and household distress are significant and substantial predictors of higher rates of drug poisoning mortality, suicide, alcohol-induced deaths, and homicide in specific regions of the U.S. However, these associations are not universal. Understanding the place-level factors that contribute to them can inform geographically tailored strategies to reduce rates from these preventable causes of death in different places.

Social Infrastructure Availability and Suicide Rates among Working-Age Adults in the United States.

Social infrastructure (SI) may buffer against suicide risk by improving social cohesion, social support, and information and resource sharing. This study uses an ecological approach to examine the relationship between county-level SI availability and suicide rates among working-age adults (ages 25-64) in the United States, a population for whom suicide rates are high, rising, and geographically unequal. Mortality data are from the National Vital Statistics System for 2016-2019. SI data are from the National Neighborhood Data Archive for 2013-2015 and capture the availability of typically free SI (e.g. libraries, community centers) and commercial SI (e.g. coffee shops, diners, entertainment venues). Results from negative binomial models show that suicide rates are significantly lower in counties with more SI availability, net of county demographic, socioeconomic, and health care factors. This relationship held for both typically free and commercial SI. Policymakers should consider strengthening existing and developing new social infrastructure, particularly in counties with less educated populations, as part of a broader strategy to reduce suicide rates in the United States.