White infant mortality in Appalachian states, 1976-1980 and 1996-2000: changing patterns and persistent disparities

Purpose: Appalachian counties have historically had elevated infant mortality rates. Changes in infant mortality disparities over time in Appalachia are not well‐understood. This study explores spatial inequalities in white infant mortality rates over time in the 13 Appalachian states, comparing counties in Appalachia with non‐Appalachian counties. Methods: Data are analyzed for 1,100 counties in 13 Appalachian states that include 420 counties designated as Appalachian by the Appalachian Regional Commission. Area Resource File data for 1976‐1980 and 1996‐2000 provide county‐ and city‐level infant mortality rates, poverty rates, rural‐urban continuum codes, and numbers of physicians per 1,000 residents. Multiple regression analyses evaluate whether Appalachian counties are significantly associated with elevated white infant mortality in each time period, accounting for covariates. Findings: White infant mortality rates decreased substantially in all sub‐regions over the last 2 decades; however, disparities in infant mortality did not diminish in Appalachian counties compared to non‐Appalachian counties. After accounting for poverty, rural/urban status, and health care resources, Appalachian counties were significantly associated with comparatively higher infant mortality during the late 1970s but not in the late 1990s. At the more recent time point, higher poverty rates, residence in more rural areas, and lower physician density were associated with greater infant mortality risk. Conclusion: Appalachian counties continue to experience relatively elevated infant mortality rates. Poverty and rurality remain important dimensions of health service need in Appalachia.     

Mortality from heart,respiratory, and kidney disease in coal mining areas of Appalachia

Purpose  The purpose of this study was to test whether population mortality rates from heart, respiratory and kidney disease were higher as a function of levels of Appalachian coal mining after control for other disease risk factors. Methods  The study investigated county-level, age-adjusted mortality rates for the years 2000–2004 for heart, respiratory and kidney disease in relation to tons of coal mined. Four groups of counties were compared: Appalachian counties with more than 4 million tons of coal mined from 2000 to 2004; Appalachian counties with mining at less than 4 million tons, non-Appalachian counties with coal mining, and other non-coal mining counties across the nation. Forms of chronic illness were contrasted with acute illness. Poisson regression models were analyzed separately for male and female mortality rates. Covariates included percent male population, college and high school education rates, poverty rates, race/ethnicity rates, primary care physician supply, rural-urban status, smoking rates and a Southern regional variable. Results  For both males and females, mortality rates in Appalachian counties with the highest level of coal mining were significantly higher relative to non-mining areas for chronic heart, respiratory and kidney disease, but were not higher for acute forms of illness. Higher rates of acute heart and respiratory mortality were found for non-Appalachian coal mining counties. Conclusions  Higher chronic heart, respiratory and kidney disease mortality in coal mining areas may partially reflect environmental exposure to particulate matter or toxic agents present in coal and released in its mining and processing. Differences between Appalachian and non-Appalachian areas may reflect different mining practices, population demographics, or mortality coding variability.     

Breast cancer mortality in Appalachia: reversing patterns of disparity over time

Breast cancer death rates in the U.S. have decreased in recent decades, however areas such as Appalachia with fewer cancer care resources may not have experienced comparable mortality declines. This study examines trends in breast cancer mortality rate disparities in Appalachian states and the continental U.S. using data from SEER mortality files 1969-2007 and the Area Resource File. Overall breast cancer mortality rates decreased significantly, with a smaller decline in Appalachian counties (17.5%) compared with non-Appalachian counties in Appalachian states (30.5%), and compared with non-Appalachia U.S. counties (28.3%). After accounting for poverty, rural/urban status, education, health care resources, and proportion White in the population, residence in Appalachian counties except for those in the Northern subregion was significantly associated with smaller reduction in breast cancer mortality rates. Lower levels of education, physician density, and percent White in the population were also associated with smaller reductions in breast cancer mortality.     

The association between mountaintop mining and birth defects among live births in central Appalachia, 1996-2003

Birth defects are examined in mountaintop coal mining areas compared to other coal mining areas and non-mining areas of central Appalachia. The study hypothesis is that higher birth-defect rates are present in mountaintop mining areas. National Center for Health Statistics natality files were used to analyze 1996–2003 live births in four Central Appalachian states (N=1,889,071). Poisson regression models that control for covariates compare birth defect prevalence rates associated with maternal residence in county mining type: mountaintop mining areas, other mining areas, or non-mining areas. The prevalence rate ratio (PRR) for any birth defect was significantly higher in mountaintop mining areas compared to non-mining areas (PRR=1.26, 95% CI=1.21, 1.32), after controlling for covariates. Rates were significantly higher in mountaintop mining areas for six of seven types of defects: circulatory/respiratory, central nervous system, musculoskeletal, gastrointestinal, urogenital, and ‘other’. There was evidence that mountaintop mining effects became more pronounced in the latter years (2000–2003) versus earlier years (1996–1999.) Spatial correlation between mountaintop mining and birth defects was also present, suggesting effects of mountaintop mining in a focal county on birth defects in neighboring counties. Elevated birth defect rates are partly a function of socioeconomic disadvantage, but remain elevated after controlling for those risks. Both socioeconomic and environmental influences in mountaintop mining areas may be contributing factors.     

Pollution Sources and Mortality Rates Across Rural-Urban Areas in the United States

Purpose: To conduct an assessment of rural environmental pollution sources and associated population mortality rates. Methods: The design is a secondary analysis of county-level data from the Environmental Protection Agency (EPA), Department of Agriculture, National Land Cover Dataset, Energy Information Administration, Centers for Disease Control and Prevention, the US Census, and others. We described the types of pollution sources present in metropolitan and nonmetropolitan counties and examined the associations between these sources and rates of all-cause, cardiovascular, respiratory, and cancer mortality while controlling for age, race, and other covariates. Findings: Rural counties had 65,055 EPA-monitored pollution discharge sites. As expected, rural counties had significantly greater exposure to potential agriculture-related pollution. Regression models specific to rural counties indicated that greater density of water pollution sources was significantly associated with greater total and cancer mortality. Rural air pollution sources were associated with greater cancer mortality rates. Rural coal mining areas had higher total, cancer, and respiratory disease mortality rates. Agricultural production was generally associated with lower mortality rates. Greater levels of human development were significantly related to higher adjusted total and cancer mortality. Conclusions: The association between pollution sources and mortality risk is not a phenomenon limited to metropolitan areas. Results carry policy implications regarding the need for effective environmental standards and monitoring. Further research is needed to better understand the types and distributions of pollution in rural areas, and the health consequences that result.     

Edentulism in High Poverty Rural Counties

Purpose: To examine the differences in oral health status among residents of high‐poverty counties, as compared to residents of other rural or urban counties, specifically on the prevalence of edentulism. Methods: We used the 2005 Behavioral Risk Factor Surveillance System (BRFSS) and the 2006 Area Resource File (ARF). All analyses were conducted with SAS and SAS‐callable SUDAAN, in order to account for weighting and the complex sample design. Findings: Characteristics significantly related to edentulism include: geographic location, gender, race, age, health status, employment, insurance, not having a usual source of care, education, marital status, presence of chronic disease, having an English interview, not deferring care due to cost, income, and dentist saturation within the county. Conclusions: Significant associations between high‐poverty rural and other rural counties and edentulism were found, and other socioeconomic and health status indicators remain strong predictors of edentulism.     

Association of long-term PM2.5 exposure with mortality using different air pollution exposure models: impacts in rural and urban California

Most PM2.5-associated mortality studies are not conducted in rural areas where mortality rates may differ when population characteristics, health care access, and PM2.5 composition differ. PM2.5-associated mortality was investigated in the elderly residing in rural–urban zip codes. Exposure (2000–2006) was estimated using different models and Poisson regression was performed using 2006 mortality data. PM2.5 models estimated comparable exposures, although subtle differences were observed in rate ratios (RR) within areas by health outcomes. Cardiovascular disease (CVD), ischemic heart disease (IHD), and cardiopulmonary disease (CPD), mortality was significantly associated with rural, urban, and statewide chronic PM2.5 exposures. We observed larger effect sizes in RRs for CVD, CPD, and all-cause (AC) with similar sizes for IHD mortality in rural areas compared to urban areas. PM2.5 was significantly associated with AC mortality in rural areas and statewide; however, in urban areas, only the most restrictive exposure model showed an association. Given the results seen, future mortality studies should consider adjusting for differences with rural–urban variables.     

Rurality and Birth Outcomes: Findings From Southern Appalachia and the Potential Role of Pregnancy Smoking

ABSTRACT:  Context: Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region. Purpose: This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations. Methods: Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records. Findings: Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking. Conclusions: Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.     

The relationship between toxics release inventory discharges and mortality rates in rural and urban areas of the United States

Background: Potential environmental exposures from chemical manufacturing or industrial sites have not been well studied for rural populations. The current study examines whether chemical releases from facilities monitored through the Toxics Release Inventory (TRI) program are associated with population mortality rates for both rural and urban populations. Methods: We used the TRI database, Centers for Disease Control and Prevention age‐adjusted mortality data, and additional county‐level covariate data to conduct a national study at (N = 3,142) of the association between amounts of on‐site TRI air and water releases for the years 1988‐2006 and total age‐adjusted mortality rates for the years 1999‐2006, after controlling for the effects of other risk variables. Results: Results of multiple linear regression analyses indicated significantly higher adjusted mortality rates associated with greater water and air releases in both rural and urban counties. The strongest associations between TRI releases and rural mortality rates were found when 8 or more prior years of TRI release data were used to study subsequent mortality. Conclusion: The results support the use of the TRI as a public reporting tool and a research tool, and demonstrate that greater amounts of air and water TRI releases are related to mortality outcomes for both rural and urban populations.     

The Relationship of Individual, Family, and Community Characteristics With Physical Health: An Adult Study in 27 Rural Minnesota Counties

CONTEXT AND PURPOSE: This study; investigates associations between the proportion of farm families in rural counties and the health of rural individuals, independent of county poverty rate and individual and family socioeconomic factors. This study also examines relationships of these socioeconomic factors and prevalence of specific diseases. METHODS: Multilevel analysis of 10,485 responses to a mailed health survey in 27 nonmetropolitan Minnesota counties. FINDINGS: Individual- and family-level variables such as age, gender, lower income, and unemployment were significantly associated with adverse physical health. The percentage of farm families in counties was significantly associated with adverse physical health of adults, independent of individual and family characteristics, county poverty rate, ethnic composition, and population density.     

Correlates of Rural,Appalachian, and Community Identity in the CITIES Cohort

Purpose : To determine correlates of rural, Appalachian, and community identity among a cohort of participants in the Community Initiative Towards Improving Equity and Health Status (CITIES) project. Methods : Mixed linear and logistic regression effects models were utilized to determine correlates of 3 outcomes: 1) community identity, 2) rural identity, and 3) Appalachian identity among participants in the Ohio CITIES project. Findings : Distinct demographic characteristics were found to be associated with each of the outcomes. For community identity, while no differences were found for rural or urban participants, those who were single or never married (P < .0001) as well as those who graduated from college (P = .0005) reported significantly lower community identity scores than married individuals with less than a college education. Those who resided in an Appalachian county reported higher community identity scores (P = .0009) than non‐Appalachian residents. For rural identity, those who did not identify as Christian (P = .018) as well as those who identified as Democrat (P = .027) reported significantly lower rural identity scores than others. Lastly, for Appalachian identity, county‐level percentage of families in poverty (P = .06), as well as gender (P = .05), were associated with self‐reported Appalachian identity, but these effects were only marginally significant. Conclusions : Although community, rural, and Appalachian identity may be viewed as similar due to their measure of attachment to a place, results from this study suggest that there are distinct individual and area‐level correlates associated with community, rural, and Appalachian identity.     

Environmental carcinogen releases and lung cancer mortality in rural-urban areas of the United States

Purpose: Environmental hazards are unevenly distributed across communities and populations; however, little is known about the distribution of environmental carcinogenic pollutants and lung cancer risk across populations defined by race, sex, and rural‐urban setting. Methods: We used the Toxics Release Inventory (TRI) database to conduct an ecological study at the county level (a total of 3,141 counties). Multiple linear regressions were used to assess the associations of carcinogenic discharges from TRI sites and lung cancer mortality rates at the county level in the United States during the years 1990 through 2007. Findings: We observed an excess risk of population lung cancer mortality associated with higher amounts of environmental carcinogen releases from TRI facilities in both males and females, and in both whites and African Americans. The strength of these associations tended to be stronger in African Americans. A significant dose‐response relationship was observed for the total volume of carcinogen releases or carcinogen releases to the air, but not releases to water. These associations appeared to be present within nonmetropolitan counties but not metropolitan counties, and to be concentrated in certain urban‐rural county typologies. Conclusions: Our results suggest that exposure to higher carcinogen releases from industrial or chemical facilities in rural areas may increase the risk of lung cancer mortality. Our findings add to the evidence for undertaking prudent efforts to limit the release of carcinogenic chemicals into the environment.     

Difference in rural and urban mortality: implications for health education and promotion.

Rural health care delivery is often inferior to that of urban areas. Although health services do not have to be identical in the two settings, quality services appropriate for the needs of rural communities are imperative. Moreover, health education and promotion should be seen as an immediate and viable strategy for (a) reducing risk factors and health care needs, and (b) increasing the cost effectiveness of existing services. The appropriateness and prioritization of health care services and health education/promotion can only be realized if health professionals are aware of rural versus urban needs. To facilitate our knowledge of such differences, the mortality rates of the 10 leading causes of death were compared for each county in Ohio and differences between rural and urban mortality were analyzed. Counties were categorized according to "density" (persons per square mile) and "percent urban" (percent of county area classified as urban). The analysis demonstrated that there were no significant differences between rural and urban counties in mortality due to cancer, pulmonary disease, diabetes mellitus, atherosclerosis, and suicide. Mortality related to cardiovascular disease, cerebrovascular disease, accidents, and influenza/pneumonia was significantly higher in rural counties, while deaths due to chronic liver disease were significantly greater in urban counties.     

Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care.

OBJECTIVES: This study examined premature mortality by county in the United States and assessed its association with metro/urban/rural geographic location, socioeconomic status, household type, and availability of medical care. METHODS: Age-adjusted years of potential life lost before 75 years of age were calculated and mapped by county. Predictors of premature mortality were determined by multiple regression analysis. RESULTS: Premature mortality was greatest in rural counties in the Southeast and Southwest. In a model predicting 55% of variation across counties, community structure factors explained more than availability of medical care. The proportions of female-headed households and Black populations were the strongest predictors, followed by variables measuring low education, American Indian population, and chronic unemployment. Greater availability of generalist physicians predicted fewer years of life lost in metropolitan counties but more in rural counties. CONCLUSIONS: Community structure factors statistically explain much of the variation in premature mortality. The degree to which premature mortality is predicted by percentage of female-headed households is important for policy-making and delivery of medical care. The relationships described argue strongly for broadening the biomedical model.     

Differential Neonatal and Postneonatal Infant Mortality Rates Across US Counties: The Role of Socioeconomic Conditions and Rurality

ABSTRACT:  Purpose: To examine differences in correlates of neonatal and postneonatal infant mortality rates, across counties, by degree of rurality. Methods: Neonatal and postneonatal mortality rates were calculated from the 1998 to 2002 Compressed Mortality Files from the National Center for Health Statistics. Bivariate analyses assessed the relationship between neonatal and postneonatal mortality by Urban Influence (UI) codes. Multivariable, weighted least-squares regression models included measures of county socioeconomic conditions, health services and environmental risks. Findings: The bivariate analysis indicated neonatal and postneonatal mortality was significantly higher in the most nonmetropolitan counties compared to the most metropolitan counties. However the relationship was not linear across the Urban Influence codes. In the multivariable models, a nonmetropolitan advantage was observed for counties not adjacent to metropolitan areas for neonatal mortality. However, postneonatal mortality rates were higher in the most rural nonmetropolitan counties. Conclusions: Certain characteristics of nonmetropolitan counties not adjacent to metropolitan counties and with an urban area of 2,500 population or more are protective against neonatal mortality (UI = 7, UI = 8). This may indicate that just having access to health services is more important to creating a protective effect for these nonmetropolitan counties than having a high concentration of medical facilities. The nonmetropolitan, not adjacent (UI = 9) disadvantage observed for postneonatal mortality supports the idea that the isolation of these areas combined with the combination of risk factors across the most nonmetropolitan counties leads to poorer postneonatal health outcomes in these areas.     

Regional variation in cardiovascular mortality in Australia 2009–2012: the impact of remoteness and socioeconomic status

Objective: To assess the extent to which socioeconomic status (SES) contributes to geographic disparity in cardiovascular disease (CVD) mortality. Methods: An ecological study assessed the association between remoteness and CVD mortality rates, and the mediating effect of SES on this relationship, using Australia‐wide data from 2009 to 2012. Results: Socioeconomic status explained approximately one‐quarter of the increased CVD mortality rates for females in inner and outer regional areas, and more than half of the increased CVD mortality rates in inner regional and remote/very remote areas for males, compared to major cities. After allowing for the mediating effect of SES, females living in inner regional areas and males living in remote/very remote areas had the greatest CVD mortality rates (Mortality Rate Ratio: 1.12, 95%CI 1.07–1.17; MRR: 1.15, 95%CI 1.05–1.25, respectively) compared to those in major cities. Conclusion: Socioeconomic status explained a substantial proportion of the association between where a person resides and CVD mortality rates; however, remoteness has an effect above and beyond SES for a number of subpopulations. Implications for public health: This study highlights the need to focus on both socioeconomic disadvantage and accessibility to reduce CVD mortality in regional and remote Australia.     

Peer Reviewed: Residence in a Distressed County in Appalachia as a Risk Factor for Diabetes,Behavioral Risk Factor Surveillance System, 2006-2007

Introduction

We compared the risk of diabetes for residents of Appalachian counties to that of residents of non-Appalachian counties after controlling for selected risk factors in states containing at least 1 Appalachian county.

Methods

We combined Behavioral Risk Factor Surveillance System data from 2006 and 2007 and conducted a logistic regression analysis, with self-reported diabetes as the dependent variable. We considered county of residence (5 classifications for Appalachian counties, based on economic development, and 1 for non-Appalachian counties), age, sex, race/ethnicity, education, household income, smoking status, physical activity level, and obesity to be independent variables. The classification "distressed" refers to counties in the worst 10%, compared with the nation as a whole, in terms of 3-year unemployment rate, per capita income, and poverty.

Results

Controlling for covariates, residents in distressed Appalachian counties had 33% higher odds (95% confidence interval, 1.10-1.60) of reporting diabetes than residents of non-Appalachian counties. We found no significant differences between other classifications of Appalachian counties and non-Appalachian counties.

Conclusions

Residents of distressed Appalachian counties are at higher risk of diabetes than are residents of other counties. States with distressed Appalachian counties should implement culturally sensitive programs to prevent diabetes.     

Metropolitan and non-metropolitan trends in coronary heart disease mortality within Appalachia, 1980-1997

OBJECTIVES: In this article, we report on metropolitan and non-metropolitan trends in coronary heart disease (CHD) mortality within the Appalachian Region for the period 1980 to 1997. We hypothesized that trends in CHD mortality would be less favorable in non-metropolitan populations with diminished access to social, economic, and medical care resources at the community level. METHODS: Our study population consisted of adults aged 35 years and older who resided within the 399 counties of the Appalachian Region between 1980 and 1997. We examined mortality trends for sixteen geo-demographic groups, defined by gender, age, race, and metropolitan status of county of residence. For each geo-demographic group, we calculated annual age-adjusted CHD mortality rates. Line graphs of these temporal trends were created, and log-linear regression models provided estimates of the average annual percent change in CHD mortality from 1980 to 1997. Data on social, economic, and medical care resources for metropolitan vs. non-metropolitan counties were also analyzed. RESULTS: Rates of CHD mortality were consistently higher in non-metropolitan areas compared with metropolitan areas for blacks of all ages and for younger whites. CHD mortality declined among almost all geo-demographic groups, but rates of decline were slower among non-metropolitan vs. metropolitan residents, blacks vs. whites, women vs. men, and older vs. younger adults. Non-metropolitan areas had fewer socioeconomic and medical care resources than metropolitan areas in 1990. CONCLUSIONS: Appalachia, particularly non-metropolitan Appalachia, needs policies and programs that will enhance both primary and secondary prevention of CHD, and help diminish racial inequalities in CHD mortality trends.     

Presence of a Community Health Center and Uninsured Emergency Department Visit Rates in Rural Counties

ABSTRACT: Context: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. Purpose: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. Methods: We analyzed data from 100% of ED visits occurring in 117 rural (non‐metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all‐cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. Findings: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all‐cause ED visits per 10,000 uninsured population compared with non‐CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11‐1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02‐1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01‐1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92‐1.22). Conclusions: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.