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Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes., Context: The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care., Methods: To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models., Findings: We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital., Conclusions: Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for., (© 2023 Milbank Memorial Fund.)

The COVID-19 pandemic has had profound impacts on access to and use of therapeutic landscapes and networks, especially for people who are vulnerable due to economic, social, and work-related disadvantage. For one such vulnerable population, Indonesian female domestic workers (FDWs) in Hong Kong, this study employed a mixed methods approach to examine the associations between perceptions of therapeutic landscapes (TLs), therapeutic networks (TNs), subjective wellbeing, and self-rated health during the COVID-19 pandemic. Data from an online survey were analyzed via structural equation modeling (SEM) and confirmatory factor analysis (CFA) to investigate the direct and indirect associations between TLs, TNs, and health and wellbeing. The findings demonstrate little or no association among FDWs' perceptions of TLs and TNs and FDWs' self-rated health and subjective wellbeing, except for a negative total association between TL and subjective wellbeing. Using insights gleaned from thematic analysis of in-depth interviews with FDWs, we suggest that these unexpected findings are mainly due to restricted access to public places, reduced social gatherings, and the fact that employers rarely granted days off during the lockdown. Although processes at the employer and municipal scales limited FDWs' access to therapeutic places, increased use of digital communications and spaces provided an important source of social and emotional support during the pandemic., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Violent crime (i.e., homicide, armed robbery, aggravated assault, and rape) continues to be a major public health concern in America. Several studies have linked the availability and density of specific features of the retail food environment, such as convenience stores and liquor stores, to violent crime rates due to the criminal activity that often occurs in and near these retailers. Nevertheless, there continues to be limited understanding of how other features (e.g., grocery stores, supercenters, restaurants, etc.) are associated with violent crime occurrence. This study aimed to fill this gap in knowledge by examining U.S. county-level associations between food retailer availability and violent crime rate., Methods: We analyzed 2014 data on 3108 counties from the U.S. Department of Agriculture's Food Environment Atlas and Department of Justice's Unified Crime Reporting Program. Per capita food retailer measures represented the number of stores per 10,000 county residents. Violent crime rate represented the number of police reported violent crimes per 10,000 county residents. We used spatial lag regression models to assess associations between per capita retailer availability and violent crime rate after adjusting for potential confounders (e.g., % under 18, % Black, % Hispanic, % poverty, population density, etc.). In addition, we examined stratified OLS regression models to evaluate associations by metropolitan county status., Results: Adjusted spatial regression models revealed that greater supercenter availability [β: 2.42; 95% CI: 0.91-3.93; p-value: 0.001] and greater fast food restaurant availability [β: 0.30; 95% CI: 0.18-0.42; p-value: < 0.001] were associated with higher violent crime rate. Greater availability of farmers' markets [β: -0.42; 95% CI: -0.77 - - 0.07); p-value: 0.02] was associated with lower violent crime rate. Associations varied between metropolitan and non-metropolitan counties. Stratified OLS models revealed that greater grocery store availability was associated with lower violent crime rate among metropolitan counties only. Greater fast food restaurant availability was associated with lower violent crime rate among non-metropolitan counties only., Conclusions: Certain features of the retail food environment appear to be associated with county-level violent crime rates in America. These findings highlight the need for additional research on the influence of food retail and food landscape on violent crime occurrence at the community level., (© 2022. The Author(s).)

Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs., (© 2022. The New York Academy of Medicine.)

Black immigrants are a growing proportion of the Black population in the USA, and despite the fact that they now comprise nearly a quarter of Black urban residents, few studies address the relationships between racial segregation and maternal and birth outcomes among Black immigrants. In this study of birth outcomes among US-born and immigrant Black mothers in New York City between 2010 and 2014, we applied multilevel models, assessing the association between segregation (measured through a novel kernel-based measure of local segregation) and adverse birth outcomes (preterm birth (PTB) and low birth weight (LBW; < 2500 g)) among African-born, Caribbean-born, and US-born Black mothers. We found that African-born and Caribbean/Latin American-born Black mothers had a significantly lower incidence of PTB compared with US-born Black mothers (7.0 and 10.1, respectively, compared with 11.2 for US-born mothers). We also found disparities in the incidence of infant LBW by nativity, with the highest incidence among infants born to US-born mothers (10.9), compared with African-born (6.9) and Caribbean-born mothers (9.0). After adjusting for maternal (maternal age; higher rates of reported drug use and smoking) and contextual characteristics (neighborhood SES; green space access), we found that maternal residence in an area with high Black segregation increases the likelihood of PTB and LBW among US-born and Caribbean-born Black mothers. In contrast, the association between segregation and birth outcomes was insignificant for African-born mothers. Associations between tract-level socioeconomic disadvantage and birth outcomes also varied across groups, with only US-born Black mothers showing the expected positive association with risk of PTB and LBW., (© 2022. The New York Academy of Medicine.)

In the late 1960s, Indonesia established community health centres (CHCs) throughout the country to provide basic healthcare services for the poor. However, CHC expenditures and investments vary widely at the sub-provincial level, among administrative areas known as cities and regencies, raising concern that facilities and services do not correspond to population needs. This study aimed to examine spatial and socioeconomic inequalities in the availability of CHCs in the Jakarta region. We used spatial and statistical analysis methods at the village level to investigate these inequalities based on CHC data from the Ministry of Health and socioeconomic data from Indonesia Statistics. Results show that CHCs and the healthcare workers within them are unevenly distributed. In areas with high need, the availability of CHCs and healthcare workers were found to be low. There is a mismatch in healthcare services and delivery for low-income, unemployed populations at the village level that needs to be addressed. The findings discussed in this paper suggest that Jakarta Department of Health should coordinate with local public health districts to determine locations for new CHCs and assign healthcare workers to each CHC based on need as this would improve access to essential health services for the low-income population.

In the U.S., substantial employment and wage gaps persist between workers with and without disabilities. A lack of accessible transportation is often cited as a barrier to employment in higher wage jobs for people with disabilities, but little is known about the intraurban commuting patterns of employed people with disabilities in relation to their wage earnings. Our study compares wages and commute times between workers with and without disabilities in the New York metropolitan region and identifies the intraurban zones where residents experience higher inequities in wage earnings and commute times. We obtained our data from the Public Use Microdata Sample (PUMS) of the American Community Survey (ACS) for the 2008-2012 time period. We used linear mixed-effects models and generated separate models with log hourly wage or one-way commute time as the dependent variable. We find significant differences in wages and commute times between workers with and without disabilities at the scale of the metropolitan region as well as by intraurban zone. At the metropolitan scale, disabled workers earn 16.6% less and commute one minute longer on average than non-disabled workers. High commute and wage inequalities converge in the center, where workers with disabilities are more likely to use public transit, earn 17.1% less, and travel nearly four minutes longer on average than workers without disabilities. These results suggest that transport options are less accessible and slower for disabled workers than they are for non-disabled workers. Our findings indicate a need for more accessible and quicker forms of transportation in the center along with an increased availability of centrally located and affordable housing to reduce the disability gap in wages and commute times. We also find that workers with disabilities generally seek higher wages in exchange for longer commute times, but the results differ by race/ethnicity and gender. Compared to white men, minority workers earn much less, and white and Hispanic women have significantly shorter commute times. Our findings offer new geographic insights on how having a disability can influence wage earnings and commute times for workers in different intraurban zones in the New York metropolitan region., Competing Interests: None., (© 2020 Elsevier Ltd. All rights reserved.)

Background: Spatial access to primary care has been associated with late-stage and fatal breast cancer, but less is known about its relation to outcomes of other screening-preventable cancers such as colorectal cancer. This population-based retrospective cohort study examined whether spatial access to primary care providers associates with colorectal cancer-specific survival., Methods: Approximately 26 600 incident colorectal cancers diagnosed between 2000 and 2008 in adults residing in Cook County, Illinois were identified through the state cancer registry and georeferenced to the census tract of residence at diagnosis. An enhanced two-step floating catchment area method measured tract-level access to primary care physicians (PCPs) in the year of diagnosis using practice locations obtained from the American Medical Association. Vital status and underlying cause of death were determined using the National Death Index. Fine-Gray proportional subdistribution hazard models analyzed the association between tract-level PCP access scores and colorectal cancer-specific survival after accounting for tract-level socioeconomic status, case demographics, tumor characteristics, and other factors., Results: Increased tract-level access to PCPs was associated with a lower risk of death from colorectal cancer (hazard ratio [HR], 95% confidence interval [CI]) = 0.87 [0.79, 0.96], P = .008, highest vs lowest quintile), especially among persons diagnosed with regional-stage tumors (HR, 95% CI = 0.80 [0.69, 0.93], P = .004, highest vs lowest quintile)., Conclusions: Spatial access to primary care providers is a predictor of colorectal cancer-specific survival in Cook County, Illinois. Future research is needed to determine which areas within the cancer care continuum are most affected by spatial accessibility to primary care such as referral for screening, accessibility of screening and diagnostic testing, referral for treatment, and access to appropriate survivorship-related care., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Introduction: To evaluate disparities in breast cancer stage by subtype (categorizations of breast cancer based upon molecular characteristics) in the Delta Regional Authority (Delta), an impoverished region across eight Lower Mississippi Delta Region (LMDR) states with a high proportion of Black residents and high breast cancer mortality rates., Methods: We used population-based cancer registry data from seven of the eight LMDR states to explore breast cancer staging (early and late) differences by subtype between the Delta and non-Delta in the LMDR and between White and Black women within the Delta. Age-adjusted incidence rates and rate ratios were calculated to examine regional and racial differences. Multilevel negative binomial regression models were constructed to evaluate how individual-level and area-level factors affect rates of early- and late-stage breast cancers by subtype., Results: For all subtypes combined, there were no Delta/non-Delta differences in early and late stage breast cancers. Delta women had lower rates of hormone-receptor (HR+)/human epidermal growth factor 2 (HER2-) and higher rates of HR-/HER2- (the most aggressive subtype) early and late stage cancers, respectively, but these elevated rates were attenuated in multilevel models. Within the Delta, Black women had higher rates of late-stage breast cancer than White women for most subtypes; elevated late-stage rates of all subtypes combined remained in Black women in multilevel analysis (RR = 1.10; 95% CI = 1.04-1.15)., Conclusions: Black women in the Delta had higher rates of late-stage cancers across subtypes. Culturally competent interventions targeting risk-appropriate screening modalities should be scaled up in the Delta to improve early detection., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Rural populations experience a myriad of cancer disparities ranging from lower screening rates to higher cancer mortality rates. These disparities are due in part to individual-level characteristics like age and insurance status, but the physical and social context of rural residence also plays a role. Our objective was two-fold: 1) to develop a multilevel conceptual framework describing how rural residence and relevant micro, macro, and supra-macro factors can be considered in evaluating disparities across the cancer control continuum and 2) to outline the unique considerations of multilevel statistical modeling in rural cancer research. We drew upon several formative frameworks that address the cancer control continuum, population-level disparities, access to health care services, and social inequities. Micro-level factors comprised individual-level characteristics that either predispose or enable individuals to utilize health care services or that may affect their cancer risk. Macro-level factors included social context (e.g. domains of social inequity) and physical context (e.g. access to care). Rural-urban status was considered a macro-level construct spanning both social and physical context, as "rural" is often characterized by sociodemographic characteristics and distance to health care services. Supra-macro-level factors included policies and systems (e.g. public health policies) that may affect cancer disparities. Our conceptual framework can guide researchers in conceptualizing multilevel statistical models to evaluate the independent contributions of rural-urban status on cancer while accounting for important micro, macro, and supra-macro factors. Statistically, potential collinearity of multilevel model predictive variables, model structure, and spatial dependence should also be considered., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To characterize spatial access to mammography services across 8 Lower Mississippi Delta Region (LMDR) states. These states include the Delta Region, a federally designated, largely rural, and impoverished region with a high proportion of black residents and low mammography utilization rates., Methods: Using the enhanced 2-step floating catchment area method, we calculated spatial accessibility scores for mammography services across LMDR census tracts. We compared accessibility scores between the Delta and non-Delta Regions of the LMDR. We also performed hotspot analysis and constructed spatial lag models to detect clusters of low spatial access and to identify sociodemographic factors associated with access, respectively. We obtained mammography facility locations data from the Food and Drug Administration and sociodemographic variables from the American Community Survey and the US Department of Agriculture., Results: Overall, there were no differences in spatial accessibility scores between the Delta and non-Delta Regions, though there was some state-to-state variation. Clusters of low spatial access were found in parts of the Arkansas, Mississippi, and Tennessee Delta. Spatial lag models found that poverty was associated with greater spatial access to mammography., Conclusions: The lack of identified differences in spatial access to mammography in the Delta and non-Delta Regions suggests that psychosocial or financial barriers play a larger role in lower mammography utilization rates. Identifying clusters of low spatial access to mammography services can help inform resource allocation. Further, our study underscores the value of using coverage-based methods rather than travel time or container measures to evaluate spatial access to care., (© 2019 National Rural Health Association.)

Purpose: To describe and elucidate rates in breast cancer incidence by subtype in the federally designated Mississippi Delta Region, an impoverished region across eight Southern/Midwest states with a high proportion of Black residents and notable breast cancer mortality disparities., Methods: Cancer registry data from seven LMDR states (Missouri was not included because of permission issues) were used to explore breast cancer incidence differences by subtype between the LMDR's Delta and non-Delta Regions and between White and Black women within the Delta Region (2012-2014). Overall and subtype-specific age-adjusted incidence rates and rate ratios were calculated. Multilevel negative binomial regression models were used to evaluate how individual-level and area-level factors, like race/ethnicity and poverty level, respectively, affect rates of breast cancers by subtype., Results: Women in the Delta Region had higher rates of triple-negative breast cancer, the most aggressive subtype, than women in the non-Delta (17.0 vs. 14.4 per 100,000), but the elevated rate was attenuated to non-statistical significance in multivariable analysis. Urban Delta women also had higher rates of triple-negative breast cancer than non-Delta urban women, which remained in multivariable analysis. In the Delta Region, Black women had higher overall breast cancer rates than their White counterparts, which remained in multivariable analysis., Conclusion: Higher rates of triple-negative breast cancer in the Delta Region may help explain the Region's mortality disparity. Further, an important area of future research is to determine what unaccounted for individual-level or social area-level factors contribute to the elevated breast cancer incidence rate among Black women in the Delta Region.

Purpose: There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review., Methods: We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions., Results: Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies., Conclusions: Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To address locally relevant cancer-related health issues, health departments frequently need data beyond that contained in standard census area-based statistics. We describe a geographic information system-based method for calculating age-standardized cancer incidence rates in non-census defined geographical areas using publically available data., Methods: Aggregated records of cancer cases diagnosed from 2009 through 2013 in each of Chicago's 77 census-defined community areas were obtained from the Illinois State Cancer Registry. Areal interpolation through dasymetric mapping of census blocks was used to redistribute populations and case counts from community areas to Chicago's 50 politically defined aldermanic wards, and ward-level age-standardized 5-year cumulative incidence rates were calculated., Results: Potential errors in redistributing populations between geographies were limited to <1.5% of the total population, and agreement between our ward population estimates and those from a frequently cited reference set of estimates was high (Pearson correlation r = 0.99, mean difference = -4 persons). A map overlay of safety-net primary care clinic locations and ward-level incidence rates for advanced-staged cancers revealed potential pathways for prevention., Conclusions: Areal interpolation through dasymetric mapping can estimate cancer rates in non-census defined geographies. This can address gaps in local cancer-related health data, inform health resource advocacy, and guide community-centered cancer prevention and control.

GIS and related spatial analysis methods provide a set of tools for describing and understanding the changing spatial organization of health care, for examining its relationship to health outcomes and access, and for exploring how the delivery of health care can be improved. This review discusses recent literature on GIS and health care. It considers the use of GIS in analyzing health care need, access, and utilization; in planning and evaluating service locations; and in spatial decision support for health care delivery. The adoption of GIS by health care researchers and policy-makers will depend on access to integrated spatial data on health services utilization and outcomes and data that cut across human service systems. We also need to understand better the spatial behaviors of health care providers and consumers in the rapidly changing health care landscape and how geographic information affects these dynamic relationships.

The authors examined the epidemiology of rodent bites occurring in New York City from 1986 through 1994 to identify factors contributing to increased probability of rodent bite and rat infestation. City blocks on which a rodent bite case had been reported (n=415) and three control blocks per bite block, matched by borough and randomly selected, were compared according to demographic characteristics obtained from US Census data. Environmental variables were defined using a geographic information system to extract distances to areas potentially providing food or refuge for rats, such as parks. Borough-specific models of bite risk were generated by logistic regression using data collected from 1991 to 1994; risk values were then generated for all city blocks. Field surveys for signs of rat infestation conducted on 31 randomly selected blocks indicated a significant association between degree of infestation and predicted risk. Spatial analyses comparing neighboring blocks showed that blocks with bite cases were significantly clustered. The models based on data from previous years correctly predicted 72 percent of 53 block addresses of rodent bite cases from 1995 as being locations of high or intermediate risk. A combination of geographic and epidemiologic analyses could help investigators identify the spatial occurrence of rat infestation over a large area and might help to focus control activities.

Geographic information systems are powerful automated systems for the capture, storage, retrieval, analysis, and display of spatial data. While the systems have been in development for more than 20 years, recent software has made them substantially easier to use for those outside the field. The systems offer new and expanding opportunities for epidemiology because they allow an informed user to choose between options when geographic distributions are part of the problem. Even when used minimally, these systems allow a spatial perspective on disease. Used to their optimum level, as tools for analysis and decision making, they are indeed a new information management vehicle with a rich potential for public health and epidemiology.