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                    [post_content] => Fewer new breast cancer cases occur annually among Hispanic women in the United States than non-Hispanic White and Black women. But breast cancer is the top cancer-related cause of death for Hispanic women.

While general breast cancer disparities by race and income are well-understood, little research highlights differences by locations as granular as counties. In a June 2018 report, researchers at Washington University in St. Louis discussed their county-level findings of breast cancer deaths across the United States between 2000 and 2015. They used data from the 2014 County Health Rankings to identify areas with particularly high observed mortality, compared to the expected rate of death from breast cancer.

As the figure depicts, the researchers found that counties with significant risk of breast cancer mortality among Hispanic women were heavily concentrated in the south and southwest. About 51 of the 83 hot spot counties (61%) were located in the south.

A closer look revealed that compared to other counties, these counties had more Hispanic residents; fewer residents in these hot spots had insurance. They also smoked less, and were less likely to receive mammography. Further, the risk of breast cancer mortality was almost 26% higher for Hispanic women in hot spots than for those living elsewhere.

The researchers suggest targeting state and local prevention to address specific issues like low insurance rates, advocating for affordable screening options, and emphasizing quality treatment in hot spot areas may help diminish some gaps that exist in breast cancer mortality.

Map: Figure 3: Breast cancer mortality hot spots, among all Hispanic women in the contiguous United States, 2000–2015  from "Mapping hot spots of breast cancer mortality in the United States: place matters for Blacks and Hispanics," Justin Xavier Moore, Kendra J. Royston, Marvin E. Langston. Russell Griffin, Bertha Hidalgo, Henry E. Wang, Graham Colditz, Tomi Akinyemiju, Cancer Causes & Control (2018) 29:737–750, https://doi.org/10.1007/s10552-018-1051-y
                    [post_title] => Where Breast Cancer Kills the Most
                    [post_excerpt] => County-level findings of breast cancer deaths across the United States between 2000 and 2015 showed significant risk of breast cancer mortality among Hispanic women in the south and southwest. 
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                    [post_date] => 2018-10-19 05:30:52
                    [post_date_gmt] => 2018-10-19 09:30:52
                    [post_content] => Rural Americans generally oppose the Affordable Care Act, even though they have benefited the most from it. To better understand how American communities differ in their health care views and experiences the Washington Post partnered with the Kaiser Family Foundation to create The Survey of Rural America. Over 1000 people living in rural America were surveyed about their political views and health experiences. As reflected in the chart above, although 95% reported Medicaid as “very important” or “somewhat important” for their local community, more than half support the repeal of the Affordable Care Act.

The ACA increased access to health insurance primarily by expanding Medicaid eligibility. Without the ACA, people are at risk of losing their Medicaid eligibility. So why do so many rural Americans support Medicaid while also supporting the repeal the ACA?

“I’ve encountered this paradox in my own research,” says Dr. David K. Jones, Assistant Professor at Boston University School of Public Health. Legislators in Kansas, for instance, supported Medicaid expansion because it provided much-needed funding to local hospitals. “Medicaid financing is critical for struggling hospitals in rural areas. Hospitals would close—indeed some have—if they lose Medicaid funding.” This would harm both patients and the hospital workforce.

Medicaid brings a wide range of health care benefits into rural communities that may be otherwise be absent. Individuals in rural areas are more likely to be self-employed and enrolled in Medicaid due to limited access to employer-sponsored health insurance. Medicaid also enrolls higher percentages of children and seniors in rural versus urban areas.
A poll conducted by Morning Consult found that only 61% of adults understood that repealing the ACA would result in lost Medicaid coverage.

 
So if Medicaid is popular in rural America, why isn’t the ACA? Jones suggests that rural residents may be confused about how their Medicaid relates to the ACA. Some states rebrand Medicaid benefits with new names, such as Wisconsin’s “Badger Care.” While marketing Medicaid directly to state residents emphasizes its importance, it may also cause confusion regarding its connection to the ACA. A poll conducted by Morning Consult found that only 61% of adults understood that repealing the ACA would result in lost Medicaid coverage.

Other rural Americans may not like the involvement of the federal government in state-run programs. The ACA expansion is directed and funded by the federal government, but administered by individual states. A 2017 study found that a primary objective for Republican legislators involved reducing the federal government’s involvement in health policy. Jones and colleagues found that some states could better implement the ACA’s policies if introduced separately from the ACA.

It’s complicated to ascertain the underlying opinions that are reflected in ACA/Medicaid public opinion paradox. Nevertheless, the benefits rural communities gain from affordable and accessible health care are undeniable.

Graphs from "The Health Care Views and Experiences of Rural Americans: Findings from the Kaiser Family Foundation/Washington Post Survey of Rural America" by Liz Hamel, Bryan Wu, and Mollyann Brodie, Figure 6 and Figure 4 (detail). 
                    [post_title] => A Rural Paradox: The Affordable Care Act or Medicaid?
                    [post_excerpt] => Why do so many rural Americans who support Medicaid also support repealing the ACA?
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                    [post_date] => 2018-10-11 07:00:55
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                    [post_content] => Most Americans have access to safe drinking water. But most isn’t all. When we narrow our focus, we find that pockets of American communities are afflicted with high levels of contaminated water. While the country was focused on Flint, Michigan’s water crisis in 2015, almost 10% of Americans were drinking contaminated water that violated water quality standards. That’s nearly 21 million people. Maura Allaire and colleagues at the University of California, Irvine examined water quality violations across the US from 1982-2015. They analyzed geographic and temporal patterns with the goal of helping state enforcement agencies focus their attention on areas at high risk of contamination.

As depicted in the graph above, rural areas were most likely to experience water quality violations compared to suburban or urban areas. Low-income rural areas were most affected, and rural counties of Texas, Oklahoma, and Idaho had the most violations. Spikes in violations were more likely to occur after implementation of new water quality standards, as communities struggled to decrease contaminant levels to match new standards.

The researchers cite decreasing population size and incomes as common obstacles faced by rural populations when following water purification standards. Rural municipalities often struggle with sufficient staffing and technical capacity to test their water. Rural residents may be less politically engaged in local water quality issues due to language barriers and education constraints.

Rural towns often rely on outside funding and low-interest government loans to support infrastructure to correct water quality violations. However, as of June 2017, over $600 million in grant funding was cut from EPA drinking water programs. The current EPA administration is looking to overturn clean water regulations implemented during the Obama administration, posing further threats towards the public’s health.

Graph by David Gaitsgory @dgaitsgo using data directly from the SDWIS Fed Reporting Services System
                    [post_title] => Water Quality Violations
                    [post_excerpt] => Most Americans have access to safe drinking water, but communities in rural areas are most likely to experience water quality violations. 
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                    [post_date] => 2018-09-27 07:00:15
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                    [post_content] => Coal workers’ pneumoconiosis or “black lung” develops when dust particles are inhaled while working in coal mines. These particles can cause both inflammation and scarring in the lungs.

In 1969, the Coal Workers’ Health Surveillance Program (CWHSP) was created with the intention of identifying and stopping the progression of black lung in coal miners. The same bill that created the CWHSP also required companies to limit coal miners’ exposure to dust.

Despite these programs and regulations, central Appalachian coal miners are experiencing a resurgence of black lung. A recent study from researchers at the National Institute for Occupational Safety and Health sought to update the prevalence estimates for black lung in the United States.

Graph A above shows the prevalence of black lung throughout the United States. Graph B shows the prevalence of black lung in central Appalachia, and graph C shows the prevalence of black lung in the United States excluding central Appalachia. In this study, central Appalachia included West Virginia, Kentucky, and Virginia.

Throughout the United States, over 10% of coal miners with 25 years or more of tenure have black lung; in central Appalachia, over 20% of miners with the same experience do. The overall prevalence of black lung in long-tenured coal miners is at its highest level in 25 years.

Feature image: “Continued Increase in Prevalence of Coal Workers’ Pneumoconiosis in the United States, 1970–2017,” David J. Blackley, Cara N. Halldin, A. Scott Laney, American Journal of Public Health 108, no. 9 (September 1, 2018): pp. 1220-1222. DOI: 10.2105/AJPH.2018.304517
                    [post_title] => Resurgence of Black Lung in Central Appalachia
                    [post_excerpt] => The Coal Workers’ Health Surveillance Program (CWHSP) was created to identify and stop the progression of black lung in coal miners. However, coal miners in central Appalachia are experiencing a resurgence of black lung.
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                    [post_content] => According to the Centers for Disease Control and Prevention, seven out of ten Americans die from chronic diseases like diabetes, heart disease, and cancer. Costs associated with using preventive services may deter people from getting screened for these conditions. Globally, other industrialized countries have fewer financial barriers to prenatal, pediatric, and other types of primary care.

Routine primary health care is critical to preventing or identifying illness in early stages when it can be treated. It has also been a core objective of population health since the 1978 Alma Ata Health for All Declaration. But research on the use of such care in the United States has focused on specific services like colorectal cancer screening and flu vaccination. Borsky et al. developed a new, more comprehensive method to measure how many adults use the high priority preventive services recommended for them. Their survey asks participants about fifteen types of evidence-based, clinically relevant preventive care, and accounted for inappropriate use and overuse.

The figure shows that, as of 2015, only 8% of all adults age 35 and older received all recommended high-priority clinical preventive services. This measure reflects the survey’s assessment of multiple types of preventive care. Taking a deeper look, Borsky and colleagues found 22.4% of surveyed adults received at least 76% of the recommended care. Compared to women, men were more likely to receive up to 25% of suggested preventive care services. Only 4.7% of all participants did not receive any recommended services. Blood pressure screenings were most commonly received, and shingles vaccinations least.

The researchers argue that the comprehensive nature of their survey instrument will be useful for health systems to assess the preventive services they offer and their receipt. They also emphasize that their questionnaire can be used at both the national and practice-specific level to help identify the impact of changes to local and national policy on preventive service use.

Graph: Health Affairs Vol. 37, NO. 6: Hospitals, Primary Care & More Datawatch, "Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services" by Amanda Borsky, Chunliu Zhan, Therese Miller, Quyen Ngo-Metzger, Arlene S. Bierman, and David Meyers, doi.org/10.1377/hlthaff.2017.1248
                    [post_title] => Preventive Care Deficit
                    [post_excerpt] => Only 8% of surveyed adults age 35 and older received all recommended high-priority clinical preventive services.
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                    [post_date] => 2018-09-20 07:00:01
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                    [post_content] => In 2006, the New York Times ranked the most common birthdays in the United States between 1973 and 1999. In the graph above, more popular birthdays are represented as darker shades of blue. September was the most common month, September 16 the most common date. The least common birth dates were February 29, December 25, and January 1.

The popularity of September birthdays isn’t happenstance. Given that September slides in nine months after December, one could presume that holiday celebrations are connected to the high number of September births. This is further evidenced by a September 16 birth date corresponding with a December 24 conception date.

A 2017 study conducted at Indiana University took a deeper look into the cultural factors that influence incidence of human sex patterns. The researchers analyzed Google search trends and Twitter data to measure intercourse frequency and mood fluctuations around Christmas and Eid-al-Fitr. They found these holidays to be closely tied to frequency of intercourse, even after adjusting for excess free-time. Higher frequency of intercourse was found to be linked to people’s elevation in happiness in direct response to the holiday season. September trends were consistent across all countries that celebrated Christmas on December 25, and birthday trends in predominantly Muslim countries moved in correspondence with the end of Ramadan.

Graph by Erin Polka 
                    [post_title] => Christmas Copulation Increases Fall Population
                    [post_excerpt] => September is the most common birthday month in the United States, with September 16 the most common birth date. The popularity of September birthdays isn’t happenstance.
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                    [post_date] => 2018-09-18 07:00:53
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                    [post_content] => The human papillomavirus (HPV) vaccine is a multi-dose series of shots to prevent an infection that already affects almost 80 million people in the United States. HPV can cause many types of cancer, including anal, genital, oral, and throat cancer. Both women and men are at risk of HPV-related cancers.

Researchers from the University of North Carolina Gillings School of Global Public Health used claims from a database of 1.3 million privately insured individuals to assess the percentage of people receiving the second and third shots in the HPV vaccine series within one year of starting, the recommended vaccination schedule. Data from individuals ages 9 to 26 years from 2006 to 2014 was used.

As shown in the graph above, female patients were more likely than male patients to receive both the second and third shots, demonstrating how difficult it is to get young patients (or the parents who transport them) to return for multiple visits of preventive care.

Though this lack of adherence to vaccination protocol looks bad at first glance, it may not have such bad effects. The CDC recommends that adolescents who start the series before their fifteenth birthday receive only a two-dose series; two shots provide adequate protection against HPV infection. But providers and parents need to be on notice that for many adolescents, males in particular, figuring out ways to get this vaccine series administered in full, will not be an easy task.

Graph: Chrissy Packtor
                    [post_title] => Multi-Dose Vaccines: Not Getting it Done
                    [post_excerpt] => The HPV vaccine requires a series of shots to prevent infection, but it is difficult to get young patients to return for multiple visits of preventive care.
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                    [post_date] => 2018-09-13 07:00:31
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                    [post_content] => Out-of-school suspension is linked to lower grades, increased expulsions, and increased risk of incarceration. Disciplinary actions are often distributed unequally, based on gender, race, and personal ability. At the request of Congress, the US Government Accountability Office (GAO) reviewed disciplinary patterns across schools. They found that Black students, boys, and students with disabilities are punished more frequently than other K-12 public school students.

As shown in the Figure, although Black students account for only 15.5% of the K-12 student population, they make up 39% of the nation’s suspensions. Boys are also overrepresented in out-of-school suspensions, as are students living with a disability.

Disciplinary action through suspension is centered around a student’s behavior, which is often influenced by myriad complex social challenges such as poverty, mental illness, and lack of parental support. Most suspensions result from multiple school absences and tardy reports which are commonly linked to difficult family situations. Chronic tardiness most affects low-income students, who often care for younger siblings or work to support their family. Furthermore, teachers’ implicit biases harbored in race and gender stereotypes also contribute to the harshness of punishment delegated. Research shows that students of color suffer from harsher disciplinary outcomes from White teachers than teachers of the same race .

Suspension as a form of punishment starts as early as preschool, where boys and black students make up the majority of suspension cases. Several school officials interviewed by the GAO reported trying to move away from disciplinary actions that remove children from the classroom, which interrupt academic achievement. Between 2016 -2017, seventeen states enacted legislation to restrict and reduce the number of out-of-school suspensions and expulsions. An elementary school official in Georgia reported that they no longer discipline based on tardiness.

Schools in Massachusetts are attempting to collaborate with mental health professionals and social workers to support students undergoing traumatic experiences. Districts in Texas and Massachusetts have introduced “personal break rooms” where children can calm down and redirect their emotions after a frustrating incident.

Feature image: "Students Suspended from School Compared to Student Population, by Race, Sex, and Disability Status, School Year 2013-14." This chart shows whether each group of students was underrepresented or overrepresented among students suspended out of school. From United States Government Accountability Office Report to Congressional Requesters, K-12 Education Discipline Disparities for Black Students, Boys, and Students with Disabilities, March 2018. 
                    [post_title] => Out of School, Out of Luck
                    [post_excerpt] => School suspension is linked to lower grades, increased expulsions, and increased risk of incarceration. Disciplinary actions are often distributed unequally, based on gender, race, and personal ability. 
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                    [post_date] => 2018-09-11 05:00:26
                    [post_date_gmt] => 2018-09-11 09:00:26
                    [post_content] => The association of American Medical Colleges predicts a shortage of 120,000 physicians overall by the year 2030, estimating a shortfall of up to 49,300 primary care physicians in the United States. The role of nurse practitioners in the primary care setting may increase, however, as their numbers are expected to rise over the next decade. In light of these predictions, Barnes and colleagues studied the trends in nurse practitioners who practiced in rural and nonrural primary care settings between 2008 and 2016.

The researchers analyzed a dataset featuring characteristics of doctors' offices, focusing on the number of nurse practitioners, physicians, and physician assistants. As the figure above depicts, they found that the proportion of nurse practitioners as a percentage of total primary care providers grew from 17.6% to 25.2% in rural areas over the observed years. Nonrural areas also saw a growth in the presence of nurse practitioners, from 15.9% to 23%. Although physicians made up the largest proportion of providers in both rural and nonrural settings, their percentage dwindled. Further, the authors found that a greater proportion of rural practices featured nurse practitioners among their provider teams compared to nonrural practices.

The Agency for Healthcare Research and Quality identifies high-functioning primary care teams as those including multidisciplinary involvement. Considering their findings, and other data documenting the high satisfaction with care from nurse practitioners and their lower practice costs compared to physicians, Barnes and the other researchers suggest that policymakers invest more in nurse practitioner education.

Feature image: "Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners," Hilary Barnes, Michael R. Richards, Matthew D. McHugh, and Grant Martsolf, Health Affairs 37, No. 6 (2018): 908–914  doi:10.1377/hlthaff.2017.1158
                    [post_title] => Nurse Practitioners and Country Living
                    [post_excerpt] => As the American Medical Colleges predicts a shortage of physicians, the role of nurse practitioners may increase. Barnes and colleagues studied the trends in nurse practitioners who practiced in rural and nonrural primary care settings. 
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                    [post_date] => 2018-08-29 06:30:44
                    [post_date_gmt] => 2018-08-29 10:30:44
                    [post_content] => Until recently, Massachusetts had one of the top state housing assistance programs in the United States for displaced families and children. In 2012, however, the state’s housing policy underwent changes, requiring shelter-seeking families with children to provide evidence they have stayed somewhere “not meant for human habitation.” Other eligibility criteria for shelter intake include having faced domestic violence, natural disasters, and no-fault eviction. Emergency rooms offers not only safety, but also discharge papers that could count as such proof of housing needs.

Kanak and colleagues recently observed how often children and young adults used the emergency department as shelter, comparing trends before and after the 2012 policy change. The researchers used medical records of youths below age 21 who visited a Boston hospital’s pediatric emergency room between Sept. 2011 and Aug. 2016 and complained of or were billed for homelessness.

As the figure above depicts, they found the median visits per month increased drastically from three visits before the policy change to 17 visits after the policy change. Most of the children observed were 12 years or younger. The emergency department’s costs and total hospital charges over the five-year period summed to nearly $580,000; only about $19,000 of that amount accrued before the policy change.

The researchers also found that more than 8,500 emergency department hours and $200,000 of Medicaid funds were used, and they suggest that this money would have been better spent to fund housing solutions. The University of Illinois Hospital, for example, helps displaced people who continuously present to the emergency department by paying their rent.

Table: “Trends in Homeless Children and Young Adults Seeking Shelter in a Boston Pediatric Emergency Department Following State Housing Policy Changes, 2011–2016," Mia Kanak, Amanda Stewart, Robert Vinci, Shanshan Liu, Megan Sandel, American Journal of Public Health 108, no. 8 (August 1, 2018): pp. 1076-1078. DOI: 10.2105/AJPH.2018.304493
                    [post_title] => Housing and Emergency Department Shelter
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