Growth and Persistence of Place-Based Mortality in the United States: The Rural Mortality Penalty.

OBJECTIVES: To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race. METHODS: We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970-2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years. RESULTS: Rural-urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties. CONCLUSIONS: The rural-urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality.

Assessing reverse 911®: a case study of the 2007 San Diego wildfires.

In October 2007, 250,000 residents of San Diego County were forced to evacuate as wildfires burned 62 miles(2) in 24 hours. In 2005, the Sheriff's Department invested in Reverse 911® to contact residents upon emergencies. The system was used during this wildfire, and by the following midday, had made 394,915 calls. Shortly thereafter, 1,210 residents were surveyed to investigate the effectiveness of this technology. Findings reveal that 42 percent of respondents received their first warning from a Reverse 911® call while an additional 7 percent received the same call, but not as their first warning, as compared to all other methods used.

Use of paid child care health care consultants in early care and education settings: results of a national study comparing provision of health screening services among Head Start and non-Head Start centers.

INTRODUCTION: Child care health consultants (CCHCs) are health professionals who provide consultation and referral services to child care programs. The use of CCHCs has been recommended as an important component of high-quality child care. The purpose of this study was to examine the potential association between the use of paid CCHCs and child care center director reports of (a) center maintenance of health records and emergency procedures and (b) center facilitation of health screenings and assessments. METHOD: A national, randomized telephone survey of directors of 1822 licensed child care center directors was conducted. RESULTS: With a response rate of 93%, most directors (72.7%) reported that they did not employ a CCHC. However, directors employing CCHCs were more likely to report provision of health-promoting screenings and assessments for children in their center. This pattern held true for both Head Start and non-Head Start centers. DISCUSSION: This study suggests that CCHCs can serve as health promotion advocates in early care and education settings, helping centers establish appropriate policies and arranging for health assessments and screenings for children.

Factors influencing diagnostic sample submission by food animal veterinarians in Mississippi.

A focus group was organised to gather information and opinions from food animal veterinarians in Mississippi regarding sample submission to diagnostic laboratories. The research found that a range of factors influence the veterinarian's decision regarding whether samples will be submitted to a diagnostic laboratory, with the cost of diagnostics as the key influence. The veterinarians believed that the relationship they had with diagnostic laboratories was important in the protection of public health, but they thought that their role in disease surveillance was under-utilised. More attention needs to be directed towards strengthening veterinary surveillance at ground level to ensure that emergent diseases are detected effectively by a partnership approach between veterinary practitioners in the field and diagnosticians in diagnostic laboratories. This partnership is a vital component of the 'One Health' concept for the protection of both animal and human health. This study demonstrates that qualitative social science methodologies, such as focus groups, can usefully be applied to topics of relevance to veterinary public health.

Gasoline prices and their relationship to drunk-driving crashes.

This study investigates the relationship between changing gasoline prices and drunk-driving crashes. Specifically, we examine the effects of gasoline prices on drunk-driving crashes in Mississippi by several crash types and demographic groups at the monthly level from 2004 to 2008, a period experiencing great fluctuation in gasoline prices. An exploratory visualization by graphs shows that higher gasoline prices are generally associated with fewer drunk-driving crashes. Higher gasoline prices depress drunk-driving crashes among young and adult drivers, among male and female drivers, and among white and black drivers. Results from negative binomial regression models show that when gas prices are higher, there are fewer drunk-driving crashes, particularly among property-damage-only crashes. When alcohol consumption levels are higher, there are more drunk-driving crashes, particularly fatal and injury crashes. The effects of gasoline prices and alcohol consumption are stronger on drunk-driving crashes than on all crashes. The findings do not vary much across different demographic groups. Overall, gasoline prices have greater effects on less severe crashes and alcohol consumption has greater effects on more severe crashes.

Gasoline prices and traffic safety in Mississippi.

PROBLEM: Limited literature suggests that gasoline prices have substantial effects on reducing fatal crashes. However, the literature focuses only on fatal crashes and does not examine the effects on all traffic crashes. METHODS: Mississippi traffic crash data from April 2004-December 2008 from the Mississippi Highway Patrol and regular-grade unleaded gasoline price data from the Energy Information Administration of the U.S. Department of Energy were used to investigate the effects of gasoline prices on traffic safety by age, gender, and race. RESULTS: Gasoline prices have both short-term and intermediate-term effects on reducing total traffic crashes and crashes of females, whites, and blacks. The intermediate-term effects are generally stronger than the short-term effects. Gasoline prices also have short-term effects on reducing crashes of younger drivers and intermediate-term effects on older drivers and male drivers. IMPACT ON INDUSTRY: Higher gasoline taxes reduce traffic crashes and may result in additional societal benefits.

Correlating pharmaceutical data with a national health survey as a proxy for estimating rural population health.

BACKGROUND: Chronic disease accounts for nearly three-quarters of US deaths, yet prevalence rates are not consistently reported at the state level and are not available at the sub-state level. This makes it difficult to assess trends in prevalence and impossible to measure sub-state differences. Such county-level differences could inform and direct the delivery of health services to those with the greatest need. METHODS: We used a database of prescription drugs filled in the US as a proxy for nationwide, county-level prevalence of three top causes of death: heart disease, stroke, and diabetes. We tested whether prescription data are statistically valid proxy measures for prevalence, using the correlation between prescriptions filled at the state level and comparable Behavioral Risk Factor Surveillance System (BRFSS) data. We further tested for statistically significant national geographic patterns. RESULTS: Fourteen correlations were tested for years in which the BRFSS questions were asked (1999-2003), and all were statistically significant. The correlations at the state level ranged from a low of 0.41 (stroke, 1999) to a high of 0.73 (heart disease, 2003). We also mapped self-reported chronic illnesses along with prescription rates associated with those illnesses. CONCLUSIONS: County prescription drug rates were shown to be valid measures of sub-state estimates of diagnosed prevalence and could be used to target health resources to counties in need. This methodology could be particularly helpful to rural areas whose prevalence rates cannot be estimated using national surveys. While there are no spatial statistically significant patterns nationally, there are significant variations within states that suggest unmet health needs.

Underlying causes of the emerging nonmetropolitan mortality penalty.

The nonmetropolitan mortality penalty results in an estimated 40 201 excessive US deaths per year, deaths that would not occur if nonmetropolitan and metropolitan residents died at the same rate. We explored the underlying causes of the nonmetropolitan mortality penalty by examining variation in cause of death. Declines in heart disease and cancer death rates in metropolitan areas drive the nonmetropolitan mortality penalty. Future work should explore why the top causes of death are higher in nonmetropolitan areas than they are in metropolitan areas.

The health of the Delta Region: a story of increasing disparities.

The Delta region of the U.S. has substantial disparities in health outcomes. For four of the leading causes of death in the United States (cardiovascular disease, cancer, stroke, and injury) residents of the Delta region are between 1.16 (cancer) and 1.45 (injury) times as likely to die as residents of the United States in general. Delta region residents are also more likely to have higher BMI, higher blood pressure, more diabetes, and are more likely to smoke. From 1968 to 1982, mortality rates in the Delta region and in the U.S. fell rapidly and in parallel. Beginning in the 1980s, these two rates continued to decline but began to diverge, with less improvement in the Delta region than in the United States in general. From 1968 to 1982, mortality disparities in the Delta were about 90 excess deaths per 100,000. By 2004, mortality disparities in the Delta had doubled to about 187 excess deaths per 100,000. Put differently, the Delta region had approximately 18,000 excess deaths in 2004, deaths that would not have occurred had the region achieved the average rate of mortality experienced by the remainder of the nation.

Preliminary evidence for an emerging nonmetropolitan mortality penalty in the United States.

We discovered an emerging non-metropolitan mortality penalty by contrasting 37 years of age-adjusted mortality rates for metropolitan versus nonmetropolitan US counties. During the 1980s, annual metropolitan-nonmetropolitan differences averaged 6.2 excess deaths per 100,000 nonmetropolitan population, or approximately 3600 excess deaths; however, by 2000 to 2004, the difference had increased more than 10 times to average 71.7 excess deaths, or approximately 35,000 excess deaths. We recommend that research be undertaken to evaluate and utilize our preliminary findings of an emerging US nonmetropolitan mortality penalty.

Evaluating heart disease presciptions-filled as a proxy for heart disease prevalence rates.

Heart disease is the leading cause of death in the U.S. Yet, prevalence rates are not reported at the county level. Not knowing how many have the disease, and where they are, may be a knowledge barrier to effective health care interventions. We use heart disease drug prescriptions-filled as a proxy measure for prevalence of heart disease. We test the correlation to the Behavioral Risk Factor Surveillance System (BRFSS) and find positive, statistically significant correlations. Next we illustrate the geographic patterns revealed using the county-level prevalence estimate maps. This information can be used to provide a better understanding of sub-state variations in disease patterns and subsequently target the delivery of health resources to small areas in need.

Persistent clusters of mortality in the United States.

We explored how place shapes mortality by examining 35 consecutive years of US mortality data. Mapping age-adjusted county mortality rates showed both persistent temporal and spatial clustering of high and low mortality rates. Counties with high mortality rates and counties with low mortality rates both experienced younger population out-migration, had economic decline, and were predominantly rural. These mortality patterns have important implications for proper research model specification and for health resource allocation policies.

Comorbidity of obesity and pain in a general population: results from the Southern Pain Prevalence Study.

UNLABELLED: This cross-sectional study examines the relation between obesity and self-reported pain (moderate or severe pain occurring at least monthly) in a general population sample of adults in the southeastern United States (N = 3637). Results of the study suggest that obese adults (body mass index [BMI] >30) are more likely to experience pain than their normal-weight and underweight counterparts. Respondents classified as class I obese (BMI of 30 to 34.9) were 1.762 times as likely as the underweight and normal weight participants to report severe pain. Class II obese respondents (BMI of 35 to 39.9) were 1.888 times as likely to experience severe pain. Those respondents categorized as class III obese were most likely to report severe pain--2.297 times as likely as the underweight and normal-weight respondents. Analyses demonstrated a similar trend for respondents reporting moderate to severe pain. Adults who are obese are also more likely to report experiencing pain in multiple locations. This study complements clinical research that links pain and obesity and extends it into a general population. Because this is a cross-sectional study, further research is needed to discern causal explanations for the relation between self-reported pain and obesity. PERSPECTIVE: This article provides a population-level depiction of the positive relation between obesity and self-reported pain, which complements clinical research on the topic. It may prompt future research to shape interventions and treatment for both pain and obesity.

Medicaid reimbursement and access to physicians: does lower reimbursement mean less access to care?

AIn 2002, Medicaid reimbursement rates were lowered. Stakeholders expressed concern that physicians would be less likely to accept Medicaid patients at the lower reimbursement rate and, consequently, Medicaid patients would have to drive farther for care. Results presented here tested those two propositions using claims data from the Mississippi Division of Medicaid. We found physicians just as likely to participate in the Medicaid program after the reimbursement rate decrease, but with higher patient loads. And, although Medicaid patients must drive farther for their care than the general population, their drive times were highest in 2002 but declined to 2001 levels by 2003. Any negative impacts from the reimbursement rate decrease on access to care for Medicaid beneficiaries appear to have been temporary. Long-term effects can be assessed with more recent claims data.

Profiles of pain in Mississippi: results from the Southern Pain Prevalence Study.

OBJECTIVES: To estimate the prevalence, intensity, frequency, and origins of pain in Mississippi residents and explore the social and cultural aspects of pain and pain management by measuring the impacts of pain on everyday life as well as respondents' beliefs and attitudes toward pain. STUDY DESIGN: Cross-sectional survey of Mississippi adults. SUMMARY OF BACKGROUND DATA: Data from previous population surveys and clinical studies indicate that pain is a pervasive part of everyday life. The prevalence, intensity and frequency of reported pain is substantial throughout these studies. The literature documents large and profound consequences of pain both for individual lives and for society. The data also suggest that beliefs and attitudes rooted in the social and cultural context of society may help explain how pain is managed or endured. METHODS: Telephone interviews with a representative sample (random digit dialing) of 604 Mississippi adults were conducted utilizing a computer-assisted telephone interviewing system. The cooperation rate was 94.8% (5.2 % refusal). The Code of Standards and Ethics for Survey Research rate was 67.4% and the maximum sampling error was +/- 4.0% (95% confidence interval). The Mississippi survey data represent a subset of the data obtained in the six-state Southern Pain Prevalence Study. RESULTS: The pain prevalence rate was estimated to be 37% of the overall Mississippi sample: 9% of the sample reported severe pain on at least a monthly basis; 16% reported moderate pain; and 12% reported mild pain. Among those reporting pain, a majority (52%) experienced pain on a daily basis. The most commonly reported origins of pain were back pain (49%), leg and knee pain (41%), and shoulder.and arm pain (20%). Respondents also reported that both moderate and severe pain had substantial negative impacts on multiple facets of everyday life, including interference with sleep (84%), recreational/leisure activities (78%), ability to work (68%), sexual relations (43%), and relationships with others (36%). Mental health impacts for respondents with moderate to severe pain on at least a monthly basis included increased feelings of anxiety (66%), self-reported depression (63%), and loneliness (46%). When responding to questions regarding beliefs and attitudes about pain and pain management, the majority of respondents (62%) considered pain to be a normal part of everyday life. Many respondents felt that medicine should be saved until the pain becomes worse (55%), and a substantial number of respondents felt that good patients do not complain about pain to their doctors (22%). CONCLUSIONS: This study expands the body of knowledge about the prevalence of pain in Mississippi, suggesting that approximately one-third of the state's adults are affected by pain on at least a monthly basis. Most of this pain is moderate to severe and quite frequent--occurring daily for the majority of pain sufferers. The study also illuminates social and cultural dimensions of pain, revealing that a) the presence of pain negatively affects almost every facet of life, from sleep and work to relationships, leisure activities, and mental health, and b) respondents attitudes and beliefs are often at variance with modern approaches to pain management. Knowledge gained could have critical implications for understanding patients and the treatment of pain.

Rural-urban differences in the social climate surrounding environmental tobacco smoke: a report from the 2002 Social Climate Survey of Tobacco Control.

CONTEXT: Although previous research has found smoking rates to be higher among residents of rural areas, few studies have investigated rural-urban differences in exposure to environmental tobacco smoke (ETS). OBJECTIVE: This study contrasted the social climate surrounding ETS among Americans who resided in 5 levels of county urbanization. DESIGN: Data were collected via telephone interviews administered to a representative sample of 3,009 civilian, noninstitutionalized adults over age 18 in the United States. Households were selected using random digit dialing procedures. FINDINGS: Compared to residents of urban counties, rural residents reported fewer restrictions on smoking in the presence of children and lower incidences of smoking bans in households, family automobiles, work areas, convenience stores, fast-food restaurants, and restaurants. Interestingly, when rural-urban variations in knowledge and attitudes about ETS were examined, the magnitude of rural-urban differences was smaller or nonexistent for these indicators. Moreover, logistic regression models indicated that none of these rural-urban differences in knowledge and attitudes persisted after statistically controlling for region, smoking status, gender, race, age, and education factors. This suggests that the observed rural-urban differences in ETS bans could not be explained adequately by rural-urban differences in knowledge and attitudes about the dangers of ETS. CONCLUSIONS: The policy implications of this research point to a greater need in rural America for programs focusing on the restriction and elimination of ETS. They also suggest that programs focusing only on influencing the levels of ETS knowledge and attitudes among the general population may not be adequate in producing the desired change.