Publications by authors named "Kirsten M M Beyer"

28 Publications

  • Page 1 of 1

Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States.

J Clin Oncol 2021 Jun 15:JCO2100112. Epub 2021 Jun 15.

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI.

Purpose: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States.

Methods: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates.

Results: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality.

Conclusion: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.
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http://dx.doi.org/10.1200/JCO.21.00112DOI Listing
June 2021

Positive Externalities of Climate Change Mitigation and Adaptation for Human Health: A Review and Conceptual Framework for Public Health Research.

Int J Environ Res Public Health 2021 03 3;18(5). Epub 2021 Mar 3.

PhD Program in Public and Community Health, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA.

Anthropogenic climate change is adversely impacting people and contributing to suffering and increased costs from climate-related diseases and injuries. In responding to this urgent and growing public health crisis, mitigation strategies are in place to reduce future greenhouse gas emissions (GHGE) while adaptation strategies exist to reduce and/or alleviate the adverse effects of climate change by increasing systems' resilience to future impacts. While these strategies have numerous positive benefits on climate change itself, they also often have other positive externalities or health co-benefits. This knowledge can be harnessed to promote and improve global public health, particularly for the most vulnerable populations. Previous conceptual models in mitigation and adaptation studies such as the shared socioeconomic pathways (SSPs) considered health in the thinking, but health outcomes were not their primary intention. Additionally, existing guidance documents such as the World Health Organization (WHO) Guidance for Climate Resilient and Environmentally Sustainable Health Care Facilities is designed primarily for public health professionals or healthcare managers in hospital settings with a primary focus on resilience. However, a detailed cross sectoral and multidisciplinary conceptual framework, which links mitigation and adaptation strategies with health outcomes as a primary end point, has not yet been developed to guide research in this area. In this paper, we briefly summarize the burden of climate change on global public health, describe important mitigation and adaptation strategies, and present key health benefits by giving context specific examples from high, middle, and low-income settings. We then provide a conceptual framework to inform future global public health research and preparedness across sectors and disciplines and outline key stakeholders recommendations in promoting climate resilient systems and advancing health equity.
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http://dx.doi.org/10.3390/ijerph18052481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967605PMC
March 2021

An adapted two-step floating catchment area method accounting for urban-rural differences in spatial access to pharmacies.

J Pharm Health Serv Res 2021 Mar 16;12(1):69-77. Epub 2021 Jan 16.

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.

Objective: To adapt the two-step floating catchment area approach to account for urban-rural differences in pharmacy access in the United States.

Methods: The urban-rural two-step floating catchment area method was described mathematically. To calculate urban-rural-two-step floating catchment area measure, census tracts and pharmacies within the study area (Southeastern Wisconsin) were classified as urban, suburban or rural, and then different catchment area sizes (2, 5 and 15 miles) were applied, based on the Centers for Medicare & Medicaid Services (CMS)' criteria for Medicare Part D service access within urban, suburban and rural areas. The urban-rural-two-step floating catchment area measures were compared to traditional two-step floating catchment area measures computed using three fixed catchment area sizes (2, 5, and 15 miles) by visually examining their spatial distributions. Associations between the four pharmacy accessibility measures and selected socio-demographics are calculated using Spearman's rank-order correlation and further compared.

Key Findings: The urban-rural two-step floating catchment area measure outperforms all the fixed catchment size measures and has the strongest Spearman correlations with the selected census variables. It also reduces the number of census tracts characterized as 'no access' when compared to the original measures. The spatial distribution of urban-rural two-step floating catchment area pharmacy access exhibits a more granular variation across the study area.

Conclusions: The results support our hypothesis that spatial access to pharmacies should account for urbanicity/rurality patterns within a region.
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http://dx.doi.org/10.1093/jphsr/rmaa022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938828PMC
March 2021

Vacant lot to community garden conversion and crime in Milwaukee: a difference-in-differences analysis.

Inj Prev 2020 Sep 10. Epub 2020 Sep 10.

Division of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.

Background: Vacant lots generate the perception of neglect and are often opportunistic locations for crime. Evidence is building to suggest that greening vacant lots, especially through community engaged approaches, is associated with reductions in some types of crime.

Methods: Using a retrospective quasi-experimental approach, we compared the conversion of vacant lots into community gardens (n=53) with a group of matched control lots (n=159) to examine the effect of this intervention on police reported theft, violent and nuisance crime in Milwaukee, Wisconsin. Conversions often involved the addition of planter boxes to create a garden, and sometimes included benches, paths, works of art or other landscaping features. Public crime data were used to generate crime rates within 100 m and 250 m around each lot.

Results: Violent and nuisance crime rates are lower near treatment lots based on an unadjusted difference-in-differences analysis of means and two Poisson regression models. While no substantial effects were observed among theft crimes, the most consistent crime rate reductions were found among violent crime within 250 m, ranging between 3.7% and 6.4% across analyses.

Conclusions: Despite the small number of interventions, community-driven vacant lot to garden conversions were associated with slight reductions in crime. Urban greening initiatives may be a promising strategy to reduce urban crime and warrant further study.
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http://dx.doi.org/10.1136/injuryprev-2020-043767DOI Listing
September 2020

Investigating the Trajectory of the COVID-19 Outbreak in Milwaukee County and Projected Effects of Relaxed Distancing.

WMJ 2020 Jun;119(2):84-90

Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin,

Introduction: The coronavirus pandemic has placed enormous stresses on health care systems across the United States and internationally. Predictive modeling has been an important tool for projecting utilization rates and surge planning. As the initial outbreak begins to slow, questions are being raised regarding long-term coronavirus mitigation plans. This paper examines the current status of the coronavirus outbreak in Milwaukee County, Wisconsin, and simulates several scenarios where physical distancing measures are removed.

Methods: The outbreak's doubling time, reproductive numbers at several points, and incidence curve were calculated to assess outbreak progression. Compartmental models were used to estimate the number of hospitalizations and critically ill patients in Milwaukee County if distancing policies were removed.

Results: The compartmental models predict a substantial spike in cases and overwhelming medical resource utilization with an abrupt end to social distancing. Partial reduction in social distancing policies would likely result in a smaller spike, with less severe strain on available medical resources.

Conclusions: Milwaukee County remains very susceptible to a resurgence of COVID-19 cases. Removing physical distancing policies poses significant risks with regard to resource management.
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June 2020

Racial disparities of liver cancer mortality in Wisconsin.

Cancer Causes Control 2019 Dec 17;30(12):1277-1282. Epub 2019 Sep 17.

Institute for Health & Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.

Purpose: To calculate tract-level estimates of liver cancer mortality in Wisconsin and identify relationships with racial and socioeconomic variables.

Methods: County-level standardized mortality ratios (SMRs) of liver cancer in Wisconsin were calculated using traditional indirect adjustment methods for cases from 2003 to 2012. Tract-level SMRs were calculated using adaptive spatial filtering (ASF). The tract-level SMRs were checked for correlations to a socioeconomic advantage index (SEA) and percent racial composition. Non-spatial and spatial regression analyses with tract-level SMR as the outcome were conducted.

Results: County-level SMR estimates were shown to mask much of the variance within counties across their tracts. Liver cancer mortality was strongly correlated with the percent of Black residents in a census tract and moderately associated with SEA. In the multivariate spatially-adjusted regression analysis, only Percent Black composition remained significantly associated with an increased liver cancer SMR.

Conclusions: Using ASF, we developed a high-resolution map of liver cancer mortality in Wisconsin. This map provided details on the distribution of liver cancer that were inaccessible in the county-level map. These tract-level estimates were associated with several racial and socioeconomic variables.
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http://dx.doi.org/10.1007/s10552-019-01232-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858574PMC
December 2019

The association of pharmacy fill synchronization with breast cancer endocrine therapy adherence.

Cancer 2019 11 2;125(22):3960-3965. Epub 2019 Aug 2.

Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: One-third to one-half of patients prescribed adjuvant endocrine therapy are nonadherent during the recommended 5-year endocrine therapy course. This study investigated whether poor pharmacy synchronization of medication fills (requiring refills on different days) acts as a barrier to adherence.

Methods: A cohort of older women with stage 0 to III endocrine receptor-positive breast cancer in 2011 was identified from the Surveillance, Epidemiology, and End Result-Medicare claims-linked cancer registry. Women with endocrine therapy and at least 1 other medication fill were identified, and the 3-month synchronization of their fills was calculated as 1 minus the quotient of the number of pharmacy visits and the number of filled medications. Regression models were used to examine the association between synchronization (in quartiles adjusted for the number of medications) and adherence to endocrine therapy (defined as a medication possession ratio ≥80%) over the subsequent year.

Results: During the 3 months after the first endocrine therapy prescription, the study cohort of 3212 women had a mean of 8.6 pharmacy visits (standard deviation, 4.7) with a mean synchronization of 0.3 (standard deviation, 0.2). Those in the third (odds ratio, 1.29; 95% confidence interval, 1.04-1.59) and fourth (most) medication number-adjusted synchronization quartiles (odds ratio, 1.49; 95% confidence interval, 1.19-1.86) were more likely to be adherent than those in the least. Multivariate model predictions showed that the proportion of patients who were adherent over 1 year varied from 68.9% in the least synchronized quartile to 76.6% in the most synchronized one.

Conclusions: Prescription refill synchronization is strongly associated with adherence to endocrine therapy. Efforts to improve adherence should address this.
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http://dx.doi.org/10.1002/cncr.32433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946341PMC
November 2019

Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas.

Cancer 2019 11 9;125(21):3818-3827. Epub 2019 Jul 9.

Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Cancer contributes substantially to the life expectancy gap between US blacks and whites, and racial cancer disparities remain stubborn to eradicate. Disparities vary geographically, suggesting that they are not inevitable.

Methods: The authors examined the relationship between housing discrimination and the size of cancer disparities across large US metropolitan statistical areas (MSAs). MSA-level cancer disparities were measured using data from the US Centers for Disease Control and Prevention. Mortgage discrimination for each MSA was estimated using the Home Mortgage Disclosure Act database, and MSA racial segregation was determined using US Census data. Patterns of housing discrimination and cancer disparities were mapped, and the associations between these place-based factors and cancer disparities across MSAs were measured.

Results: Black-to-white cancer mortality disparities (rate ratios) varied geographically, ranging from 1.50 to 0.86; 88% of mortality ratios were >1, indicating higher mortality for blacks. In areas with greater mortgage discrimination, the gap between black and white cancer mortality rates was larger (correlation coefficient [r] = 0.32; P = .001). This relationship persisted in sex-specific analyses (males, r = 0.37; P < .001; females, r = 0.23; P = .02) and in models controlling for confounders. In contrast, segregation was inconsistently associated with disparities. Adjusting for incidence disparities attenuated, but did not eliminate, the correlation between mortgage discrimination and mortality disparities (r = 0.22-0.24), suggesting that cancer incidence and survival each account for part of the mortality disparity.

Conclusions: Mortgage discrimination is associated with larger black-to-white cancer mortality disparities. Some areas are exceptions to this trend. Examination of these exceptions and of policies related to housing discrimination may offer novel strategies for explaining and eliminating cancer disparities.
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http://dx.doi.org/10.1002/cncr.32358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788939PMC
November 2019

Exposure to neighborhood green space and sleep: evidence from the Survey of the Health of Wisconsin.

Sleep Health 2018 10 24;4(5):413-419. Epub 2018 Aug 24.

Division of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.

Introduction: Adequate sleep duration and quality are protective against many adverse health outcomes. Many individual-level predictors of poor sleep have been examined, but few studies have examined neighborhood-level influences. Despite known associations between neighborhood green space and sleep influencing factors (eg, physical activity, mental health), few studies have examined green space and sleep's relationship. Furthermore, little work has examined the relationship between the magnitude and type of neighborhood sounds and sleep.

Study Methods: We analyzed data from the Survey of the Health of Wisconsin database (n = 2712) for 2008-2013, a representative sample of Wisconsin residents ages 21-74. Outcomes included weekday and weekend sleep duration and self-rated sleep quality. Primary predictors were the proportion tree canopy (National Land Cover Database) and mean decibel levels of outdoor sound (US National Park Service) at the census block group level. Survey regression analysis was used to examine statistical associations, controlling for individual and neighborhood-level covariates.

Results: Models suggest a significant relationship (P < .05) between weekday sleep duration and green space, and between weekend/day sleep duration and human-made and total neighborhood sound. Increased percent tree canopy in a census block group was associated with lower odds of short weekday sleep (<6 hours) (OR 0.76 [0.58-0.98]). Increased human-made and total mean decibel levels were associated with increased instances of short weekend and weekday sleep (OR 1.05 [1.01-1.08] and 1.03 [1.01-1.06] respectively).

Conclusions: Neighborhood tree canopy and sound levels may influence sleep duration and are potential targets for neighborhood-level interventions to improve sleep.
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http://dx.doi.org/10.1016/j.sleh.2018.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6152838PMC
October 2018

Time spent outdoors, activity levels, and chronic disease among American adults.

J Behav Med 2018 08 30;41(4):494-503. Epub 2018 Jan 30.

Department of Medicine, Cancer Center, and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, P.O. Box 26509, Milwaukee, WI, 53226-0509, USA.

Chronic diseases-including cancer, cardiovascular diseases, and metabolic conditions such as diabetes and obesity-account for over 60% of overall global mortality. Sedentary time increases the risk for chronic disease incidence and mortality, while moderate to vigorous physical activity is known to decrease risk. Most Americans spend at least half of their time sedentary, with a trend toward increasingly sedentary lifestyles, and few Americans achieve recommended levels of physical activity. Time spent outdoors has been associated with reduced sedentary time and increased physical activity among children/youth and the elderly, but few population-based studies have examined this relationship among working age adults who may face greater constraints on active, outdoor time. This study examines the relationship between time spent outdoors, activity levels, and several chronic health conditions among a population-based sample of working age American adults in the National Health and Nutrition Examination Survey (NHANES) for 2009-2012. Findings provide evidence that time spent outdoors, on both work days and non-work days, is associated with less time spent sedentary and more time spent in moderate to vigorous physical activity. Further, findings indicate that time spent outdoors is associated with lower chronic disease risk; while these associations are partially explained by activity levels, controlling for activity levels does not fully attenuate the relationship between time outdoors and chronic disease risk. While cross-sectional, study findings support the notion that increasing time spent outdoors could result in more active lifestyles and lower chronic disease risk. Future work should examine this relationship longitudinally to determine a causal direction. Additional work is also needed to identify mechanisms beyond physical activity, such as psychosocial stress, that could contribute to explaining the relationship between time spent outdoors and chronic disease risk.
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http://dx.doi.org/10.1007/s10865-018-9911-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031452PMC
August 2018

The spatial epidemiology of pediatric trauma: A statewide assessment.

J Trauma Acute Care Surg 2017 08;83(2):225-229

From the Institute for Health and Society (A.M.E., K.M.M.B., S.T., Y.Z., L.D.C.), Medical College of Wisconsin, Milwaukee, Wisconsin; and Nationwide Children's Hospital, (J.I.G.) Columbus, Ohio.

Background: Despite significant advances in the prevention and treatment of pediatric trauma, preventable injuries continue to burden the lives of millions of children. To target prevention strategies, it is critical to identify areas with high burdens of pediatric trauma. Therefore, this study analyzed statewide data from the Ohio Trauma Registry from 2007 to 2012 to identify geographical patterns in pediatric injury.

Methods: Data from the first hospital of care for 16,330 pediatric trauma patients younger than 16 years were analyzed using the disease mapping method adaptive spatial filtering to estimate a series of maps that display age- and sex-adjusted rates of pediatric trauma, severe trauma, and standardized mortality ratios while controlling for population size to create stable estimates throughout the study area. The locations of all trauma centers were mapped to highlight access to trauma care.

Results: Areas with significantly higher than expected rates of severe injury were identified in nonurban areas, where children lacked timely access to a pediatric trauma center or Level I adult trauma center. Although highest standardized mortality ratios were in urban areas, nonurban areas experienced elevated mortality with rates over four times higher than expected.

Conclusion: Areas with higher than expected age- and sex-adjusted rates of severe injury and mortality should be further explored to identify opportunities for injury prevention and appropriate access to timely care.

Level Of Evidence: Epidemiologic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522352PMC
August 2017

Measures Matter: The Local Exposure/Isolation (LEx/Is) Metrics and Relationships between Local-Level Segregation and Breast Cancer Survival.

Cancer Epidemiol Biomarkers Prev 2017 04 21;26(4):516-524. Epub 2017 Mar 21.

Division of Epidemiology, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin.

The Black-to-White disparity in breast cancer survival is increasing, and racial residential segregation is a potential driver for this trend. However, study findings have been mixed, and no study has comprehensively compared the effectiveness of different local-level segregation metrics in explaining cancer survival. We proposed a set of new local segregation metrics named local exposure and isolation (LEx/Is) and compared our new local isolation metric with two related metrics, the location quotient (LQ) and the index of concentration at extremes (ICE), across the 102 largest U.S. metropolitan areas. Then, using case data from the Milwaukee, WI, metropolitan area, we used proportional hazards models to explore associations between segregation and breast cancer survival. Across the 102 metropolitan areas, the new local isolation metric was less skewed than the LQ or ICE. Across all races, Hispanic isolation was associated with poorer all-cause survival, and Hispanic LQ and Hispanic-White ICE were found to be associated with poorer survival for both breast cancer-specific and all-cause mortality. For Black patients, Black LQ was associated with lower all-cause mortality and Black local isolation was associated with reduced all-cause and breast cancer-specific mortality. ICE was found to suffer from high multicollinearity. Local segregation is associated with breast cancer survival, but associations varied based on patient race and metric employed. We highlight how selection of a segregation measure can alter study findings. These relationships need to be validated in other geographic areas.
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http://dx.doi.org/10.1158/1055-9965.EPI-16-0926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380473PMC
April 2017

Housing Discrimination, Residential Racial Segregation, and Colorectal Cancer Survival in Southeastern Wisconsin.

Cancer Epidemiol Biomarkers Prev 2017 04 14;26(4):561-568. Epub 2017 Feb 14.

Division of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin.

Residential racial segregation is still neglected in contemporary examinations of racial health disparities, including studies of cancer. Even fewer studies examine the processes by which segregation occurs, such as through housing discrimination. This study aims to examine relationships among housing discrimination, segregation, and colorectal cancer survival in southeastern Wisconsin. Cancer incidence data were obtained from the Wisconsin Cancer Reporting System for two southeastern Wisconsin metropolitan areas. Two indices of mortgage discrimination were derived from Home Mortgage Disclosure Act data, and a measure of segregation (the location quotient) was calculated from U.S. census data; all predictors were specified at the ZIP Code Tabulation Area level. Cox proportional hazards regression was used to examine associations between mortgage discrimination, segregation, and colorectal cancer survival in southeastern Wisconsin. For all-cause mortality, racial bias in mortgage lending was significantly associated with a greater hazard rate among blacks [HR = 1.37; 95% confidence interval (CI), 1.06-1.76] and among black women (HR = 1.53; 95% CI, 1.06-2.21), but not black men in sex-specific models. No associations were identified for redlining or the location quotient. Additional work is needed to determine whether these findings can be replicated in other geographical settings. Our findings indicate that black women in particular experience poorer colorectal cancer survival in neighborhoods characterized by racial bias in mortgage lending, a measure of institutional racism. These findings are in line with previous studies of breast cancer survival. Housing discrimination and institutional racism may be important targets for policy change to reduce health disparities, including cancer disparities.
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http://dx.doi.org/10.1158/1055-9965.EPI-16-0929DOI Listing
April 2017

Raising rural women's voices: From self-silencing to self-expression.

J Women Aging 2017 Nov-Dec;29(6):515-529. Epub 2016 Dec 29.

c Division of Epidemiology, Institute for Health & Society , Medical College of Wisconsin , Milwaukee , Wisconsin , USA.

Within the context of a community-academic partnership, we undertook a mixed-methods study to identify and explore health status, priorities, and management strategies among aging Wisconsin rural women. A questionnaire measuring diverse wellness needs was administered to women participating in personal development programming offered by a rural nonprofit organization. A subgroup participated in qualitative interviews to deepen the understanding of identified health priorities and methods of coping and healing. Findings provide insight into the prevalence of self-silencing among rural women and highlight mechanisms that help to facilitate the dismantling of self-silencing.
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http://dx.doi.org/10.1080/08952841.2016.1256732DOI Listing
June 2018

Time Spent Outdoors, Depressive Symptoms, and Variation by Race and Ethnicity.

Am J Prev Med 2016 09 16;51(3):281-90. Epub 2016 Jun 16.

Department of Medicine and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin.

Introduction: Numerous studies have explored neighborhood environmental correlates of mental illnesses, presuming that the time individuals spend in their environment can confer benefit or harm based on environmental characteristics. However, few population-based studies have directly examined the relationship between time spent outdoors and mental health, and little work has been done to explore how experiences differ by race and ethnicity. Though some have proposed "doses of outdoor time" to improve health, the absence of information about the benefits conferred by particular "doses," and expected baseline levels of outdoor time, are needed to inform the development of recommendations and interventions.

Methods: This study examined the relationship between time spent outdoors and depression among a population-based sample of American adults, characterized current levels of time spent outdoors by race and ethnicity, and examined how the relationship between time spent outdoors and depression varies by race and ethnicity. Descriptive statistics and survey regression models were used to examine data from the National Health and Nutrition Examination Survey for 2009-2012.

Results: Findings provide evidence that time spent outdoors is associated with fewer depressive symptoms, but this benefit may not be equally distributed by race and ethnicity. Descriptive analyses also reveal differences in time spent outdoors among different racial and ethnic groups.

Conclusions: Study findings support the notion that increasing time spent outdoors may result in mental health benefits. However, this study questions whether that benefit is experienced equally among different groups, particularly given differences in occupational experiences and environmental characteristics of neighborhoods.
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http://dx.doi.org/10.1016/j.amepre.2016.05.004DOI Listing
September 2016

The Effects of Geographic Isolation and Social Support on the Health of Wisconsin Women.

WMJ 2016 Apr;115(2):65-9

Background: Rural residents are less likely to receive preventive health screening, more likely to be uninsured, and more likely to report fair to poor health than urban residents. Social disconnectedness and perceived isolation are known to be negative predictors of self-rated physical health; however, the direct effects of geographic isolation and social support on overall health have not been well elucidated.

Methods: A cross-sectional survey of women (n = 113) participating in Wisconsin Rural Women's initiative programming was conducted, which included measures of geographic isolation, an assessment of overall health, and social support using the validated Interpersonal Support Evaluation List with 3 subscales, including belonging support, tangible support, and appraisal support.

Results: Geographic isolation was shown to be a negative predictor of belonging support (P = .0064) and tangible support (P = .0349); however, geographic isolation was not a statistically significant predictor of appraisal support. A strong and direct relationship was observed between social support and self-perceived health status among this population of Wisconsin women, and hospital access based on geographic proximity was positively correlated (P = .028) with overall health status.

Conclusions: The direct relationship between social support and overall health demonstrated here stresses the importance of developing and maintaining strong social support networks, which can be improved through rural support groups that have the unique ability to assist rural residents in fostering social support systems, advocating stress management techniques, and achieving a greater sense of well-being.
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April 2016

New spatially continuous indices of redlining and racial bias in mortgage lending: links to survival after breast cancer diagnosis and implications for health disparities research.

Health Place 2016 07 9;40:34-43. Epub 2016 May 9.

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226-0509, USA; Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226-0509, USA.

Racial health disparities continue to be a serious problem in the United States and have been linked to contextual factors, including racial segregation. In some cases, including breast cancer survival, racial disparities appear to be worsening. Using the Home Mortgage Disclosure Act (HMDA) database, we extend current spatial analysis methodology to derive new, spatially continuous indices of (1) racial bias in mortgage lending and (2) redlining. We then examine spatial patterns of these indices and the association between these new measures and breast cancer survival among Black/African American women in the Milwaukee, Wisconsin metropolitan area. These new measures can be used to examine relationships between mortgage discrimination and patterns of disease throughout the United States.
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http://dx.doi.org/10.1016/j.healthplace.2016.04.014DOI Listing
July 2016

Breast and Colorectal Cancer Survival Disparities in Southeastern Wisconsin.

WMJ 2016 Feb;115(1):17-21

Background: Cancer health disparities by race, ethnicity, socioeconomic status, and geography are a top public health priority. Breast and colorectal cancer, in particular, have been shown to exhibit significant disparities and contribute a large proportion of morbidity and mortality from cancer. In addition, breast and colorectal cancer offer targets for prevention and control, including nutrition, physical activity, screening, and effective treatments to prolong and enhance the quality of survival. However, despite the investment of significant time and resources over many years, breast and colorectal cancer disparities persist, and in some cases, may be growing.

Methods: This paper examines breast and colorectal cancer survival disparities in an 8-county region in southeastern Wisconsin, including the City of Milwaukee. Cox proportional hazards models were used to examine survival trends, and a new adaptation of adaptive spatial filtering--a disease mapping method--was used to examine spatial patterns of survival.

Results: Disparities by race and ethnicity are revealed, and spatial analyses identify specific areas within the study region that have lower than expected survival rates.

Conclusions: Cancer control efforts in southeastern Wisconsin should focus on black/African American and Hispanic/Latina women to reduce breast cancer survival disparities, and black/African American populations to reduce colorectal cancer disparities. Evidence indicates that targeted interventions may be needed to serve populations in the Milwaukee and Kenosha metropolitan areas, as well as areas of Walworth, Ozaukee, and Waukesha counties.
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February 2016

Travel distances by Wisconsin Medicaid enrollees who visit emergency departments for dental care.

J Public Health Dent 2016 06 21;76(3):213-9. Epub 2016 Jan 21.

Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA.

Objectives: Prior studies document increased numbers of nontraumatic dental condition (NTDC) visits to U.S. emergency departments (EDs). However, the influence of travel distance on ED use for NTDCs, particularly for Medicaid enrollees has hitherto received little attention. The authors examined the effect of travel distance on Wisconsin Medicaid enrollees' NTDC visits to EDs after adjustment for covariates.

Methods: NTDC-related visits claims data for Wisconsin Medicaid (2001-2009) was analyzed. For each enrollee, travel distance to the nearest of 130 EDs in Wisconsin was determined. The number of NTDC visits per person-year was aggregated by ZIP+4 of residence. Negative binomial regression adjusting for the expected number of visits based on race, sex, age of the residents and calendar year was used to evaluate the effect of travel distance, urbanicity, and dentist-population ratio on rate of visits.

Results: Enrollees residing in rural counties, entire dental health professional shortage areas, areas with dentist population ratios >20,000: 1 and non-Hispanic Whites travelled the furthest, compared to nearest mean ED distance of 2.9 miles. Enrollees residing 3 miles away or further had significantly lower rates of NTDC visits to EDs.

Conclusions: This study demonstrates that distance is a barrier to making NTDC-related visits to EDs. Rates of NTDC visits decreased as travel distance to the nearest ED increased for Medicaid enrollees.
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http://dx.doi.org/10.1111/jphd.12138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4956604PMC
June 2016

Perceived Neighborhood Quality and Cancer Screening Behavior: Evidence from the Survey of the Health of Wisconsin.

J Community Health 2016 Feb;41(1):134-7

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA.

Socioeconomic disparities in colorectal and breast cancer screening persist, partially accounting for disparities in cancer outcomes. Some neighborhood characteristics--particularly area level socioeconomic factors--have been linked to cancer screening behavior, but few studies have examined the relationship between perceived neighborhood quality and screening behavior, which may provide more insight into the ways in which neighborhood environments shape cancer related behaviors. This study examines the relationship between several aspects of the perceived neighborhood environment and breast and colorectal cancer screening behavior among a population-based sample of Wisconsin residents. A sub-goal was to compare the relevance of different perceived neighborhood factors for different screening tests. This is a cross-sectional study of 2008-2012 data from the Survey of the Health of Wisconsin, a population-based annual survey of Wisconsin residents. An average risk sample of Black, Hispanic and White women age 50 and older (n = 1265) were selected. Survey regression analyses examined predictors of screening, as well as adherence to screening guidelines. Models controlled for individual socio-demographic information and insurance status. Perceptions of social and physical disorder, including fear of crime and visible garbage, were associated with screening rates. Findings emphasize the particular importance of these factors for colorectal cancer screening, indicating the necessity of improving screening rates in areas characterized by social disorganization, crime, and physical disorder. Additional work should be done to further investigate the pathways that explain the linkage between neighborhood conditions, perceived neighborhood risks and cancer screening behavior.
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http://dx.doi.org/10.1007/s10900-015-0078-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984667PMC
February 2016

More than a pretty place: assessing the impact of environmental education on children's knowledge and attitudes about outdoor play in nature.

Int J Environ Res Public Health 2015 Feb 12;12(2):2054-70. Epub 2015 Feb 12.

Menomonee Valley Partners, Inc., 301 W. Wisconsin Ave., Suite 400B, Milwaukee, WI 53203, USA.

Our work assessed the influence of an urban environmental education program on children's attitudes toward outdoor play, as well as knowledge of neighborhood features that can facilitate this type of activity. The project team engaged 6 schools near the newest Urban Ecology Center location in Milwaukee, Wisconsin, USA, through a community-academic partnership entitled More Than a Pretty Place. Intervention classrooms participated in programming over the 2012-2013 academic year and pre and post surveys were implemented in classrooms. Data were analyzed using multilevel regression models. The intervention group reported reduced fears of outdoor play in nature and increased frequency of visits to the Urban Ecology Center. The proportion of students who acknowledged knowing of a place to play outside in nature increased significantly in both groups. Our findings indicate an important role for environmental education in addressing fears that may dissuade children from engaging in outdoor play in natural areas.
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http://dx.doi.org/10.3390/ijerph120202054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344710PMC
February 2015

More than a pretty place: assessing the impact of environmental education on children's knowledge and attitudes about outdoor play in nature.

Int J Environ Res Public Health 2015 Feb 12;12(2):2054-70. Epub 2015 Feb 12.

Menomonee Valley Partners, Inc., 301 W. Wisconsin Ave., Suite 400B, Milwaukee, WI 53203, USA.

Our work assessed the influence of an urban environmental education program on children's attitudes toward outdoor play, as well as knowledge of neighborhood features that can facilitate this type of activity. The project team engaged 6 schools near the newest Urban Ecology Center location in Milwaukee, Wisconsin, USA, through a community-academic partnership entitled More Than a Pretty Place. Intervention classrooms participated in programming over the 2012-2013 academic year and pre and post surveys were implemented in classrooms. Data were analyzed using multilevel regression models. The intervention group reported reduced fears of outdoor play in nature and increased frequency of visits to the Urban Ecology Center. The proportion of students who acknowledged knowing of a place to play outside in nature increased significantly in both groups. Our findings indicate an important role for environmental education in addressing fears that may dissuade children from engaging in outdoor play in natural areas.
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http://dx.doi.org/10.3390/ijerph120202054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344710PMC
February 2015

Exposure to neighborhood green space and mental health: evidence from the survey of the health of Wisconsin.

Int J Environ Res Public Health 2014 Mar 21;11(3):3453-72. Epub 2014 Mar 21.

Department of Population Health Sciences, University of Wisconsin-Madison, Wisconsin Alumni Research Foundation, 610 Walnut St., Madison, WI 53726, USA.

Green space is now widely viewed as a health-promoting characteristic of residential environments, and has been linked to mental health benefits such as recovery from mental fatigue and reduced stress, particularly through experimental work in environmental psychology. Few population level studies have examined the relationships between green space and mental health. Further, few studies have considered the role of green space in non-urban settings. This study contributes a population-level perspective from the United States to examine the relationship between environmental green space and mental health outcomes in a study area that includes a spectrum of urban to rural environments. Multivariate survey regression analyses examine the association between green space and mental health using the unique, population-based Survey of the Health of Wisconsin database. Analyses were adjusted for length of residence in the neighborhood to reduce the impact of neighborhood selection bias. Higher levels of neighborhood green space were associated with significantly lower levels of symptomology for depression, anxiety and stress, after controlling for a wide range of confounding factors. Results suggest that "greening" could be a potential population mental health improvement strategy in the United States.
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http://dx.doi.org/10.3390/ijerph110303453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987044PMC
March 2014

Characteristics of the residential neighborhood environment differentiate intimate partner femicide in urban versus rural settings.

J Rural Health 2013 Jun 14;29(3):281-93. Epub 2013 Jan 14.

Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.

Purpose: A growing body of work examines the association between neighborhood environment and intimate partner violence (IPV). As in the larger literature examining the influence of place context on health, rural settings are understudied and urban and rural residential environments are rarely compared. In addition, despite increased attention to the linkages between neighborhood environment and IPV, few studies have examined the influence of neighborhood context on intimate partner femicide (IPF). In this paper, we examine the role for neighborhood-level factors in differentiating urban and rural IPFs in Wisconsin, USA.

Methods: We use a combination of Wisconsin Violent Death Reporting System (WVDRS) data and Wisconsin Coalition Against Domestic Violence (WCADV) reports from 2004 to 2008, in concert with neighborhood-level information from the US Census Bureau and US Department of Agriculture, to compare urban and rural IPFs.

Findings: Rates of IPF vary based on degree of rurality, and bivariate analyses show differences between urban and rural victims in race/ethnicity, marital status, country of birth, and neighborhood characteristics. After controlling for individual characteristics, the nature of the residential neighborhood environment significantly differentiates urban and rural IPFs.

Conclusions: Our findings suggest a different role for neighborhood context in affecting intimate violence risk in rural settings, and that different measures may be needed to capture the qualities of rural environments that affect intimate violence risk. Our findings reinforce the argument that multilevel strategies are required to understand and reduce the burden of intimate violence, and that interventions may need to be crafted for specific geographical contexts.
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http://dx.doi.org/10.1111/j.1748-0361.2012.00448.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3695409PMC
June 2013

A probabilistic sampling method (PSM) for estimating geographic distance to health services when only the region of residence is known.

Int J Health Geogr 2011 Jan 10;10. Epub 2011 Jan 10.

Institute for Health and Society, Medical College of Wisconsin, Milwaukee, 53226, USA.

Background: The need to estimate the distance from an individual to a service provider is common in public health research. However, estimated distances are often imprecise and, we suspect, biased due to a lack of specific residential location data. In many cases, to protect subject confidentiality, data sets contain only a ZIP Code or a county.

Results: This paper describes an algorithm, known as "the probabilistic sampling method" (PSM), which was used to create a distribution of estimated distances to a health facility for a person whose region of residence was known, but for which demographic details and centroids were known for smaller areas within the region. From this distribution, the median distance is the most likely distance to the facility. The algorithm, using Monte Carlo sampling methods, drew a probabilistic sample of all the smaller areas (Census blocks) within each participant's reported region (ZIP Code), weighting these areas by the number of residents in the same age group as the participant. To test the PSM, we used data from a large cross-sectional study that screened women at a clinic for intimate partner violence (IPV). We had data on each woman's age and ZIP Code, but no precise residential address. We used the PSM to select a sample of census blocks, then calculated network distances from each census block's centroid to the closest IPV facility, resulting in a distribution of distances from these locations to the geocoded locations of known IPV services. We selected the median distance as the most likely distance traveled and computed confidence intervals that describe the shortest and longest distance within which any given percent of the distance estimates lie. We compared our results to those obtained using two other geocoding approaches. We show that one method overestimated the most likely distance and the other underestimated it. Neither of the alternative methods produced confidence intervals for the distance estimates. The algorithm was implemented in R code.

Conclusions: The PSM has a number of benefits over traditional geocoding approaches. This methodology improves the precision of estimates of geographic access to services when complete residential address information is unavailable and, by computing the expected distribution of possible distances for any respondent and associated distance confidence limits, sensitivity analyses on distance access measures are possible. Faulty or imprecise distance measures may compromise decisions about service location and misdirect scarce resources.
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http://dx.doi.org/10.1186/1476-072X-10-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024211PMC
January 2011

Explaining place-based colorectal cancer health disparities: evidence from a rural context.

Soc Sci Med 2011 Feb 8;72(3):373-82. Epub 2010 Oct 8.

Medical College of Wisconsin, Institute for Health and Society, 8701 Watertown Plank Road, Milwaukee, WI 53226, United States.

A growing body of work examines geographical setting as a source of health disparity, hypothesizing individual as well as larger, environmental sources of risk. However, mechanisms by which this influence operates, especially in rural settings, are not well understood. This study investigates the problem of colorectal cancer in a rural US community through the lens of geographical setting. Statewide maps of colorectal cancer burdens show a place-based disparity in colorectal cancer in the region surrounding a small, diverse Iowa community. Within a research partnership framework, we use these maps to engage community residents in discussions of high colorectal cancer rates. We ask how a rural community experiencing higher than expected rates of colorectal cancer late-stage diagnosis and mortality perceives and explains their increased risk, interpreting available epidemiological evidence based on their lived experience. We use concept mapping to organize these perceptions and situate our findings in the context of previous work. Our findings reveal a complex understanding of risk that should be taken into account in crafting effective public health interventions and messages. Our work informs the growing literature on how context influences individual experiences of health problems, with specific relevance for rural populations.
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http://dx.doi.org/10.1016/j.socscimed.2010.09.017DOI Listing
February 2011

Disease maps as context for community mapping: a methodological approach for linking confidential health information with local geographical knowledge for community health research.

J Community Health 2010 Dec;35(6):635-44

Department of Population Health, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.

Health is increasingly understood as a product of multiple levels of influence, from individual biological and behavioral influences to community and societal level contextual influences. In understanding these contextual influences, community health researchers have increasingly employed both geographic methodologies, including Geographic Information Systems (GIS), and community participatory approaches. However, despite growing interest in the role for community participation and local knowledge in community health investigations, and the use of geographical methods and datasets in characterizing community environments, there exist few examples of research projects that incorporate both geographical and participatory approaches in addressing health questions. This is likely due in part to concerns and restrictions regarding community access to confidential health data. In order to overcome this barrier, we present a method for linking confidential, geocoded health information with community-generated experiential geographical information in a GIS environment. We use sophisticated disease mapping methodologies to create continuously defined maps of colorectal cancer in Iowa, then incorporate these layers in an open source GIS application as the context for a participatory community mapping exercise with participants from a rural Iowa town. Our method allows participants to interact directly with health information at a fine geographical scale, facilitating hypothesis generation regarding contextual influences on health, while simultaneously protecting data confidentiality. Participants are able to use their local, geographical knowledge to generate hypotheses about factors influencing colorectal cancer risk in the community and opportunities for risk reduction. This work opens the door for future efforts to integrate empirical epidemiological data with community generated experiential information to inform community health research and practice.
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http://dx.doi.org/10.1007/s10900-010-9254-5DOI Listing
December 2010

Mapping cancer for community engagement.

Prev Chronic Dis 2009 Jan 15;6(1):A03. Epub 2008 Dec 15.

Dept of Geography, University of Iowa, Iowa City, IA 52242, USA.

Introduction: Two research strategies may reduce health disparities: community participation and the use of geographic information systems. When combined with community participation, geographic information systems approaches, such as the creation of disease maps that connect disease rates with community context, can catalyze action to reduce health disparities. However, current approaches to disease mapping often focus on the display of disease rates for political or administrative units. This type of map does not provide enough information on the local rates of cancer to engage community participation in addressing disparities.

Methods: We collaborated with researchers and cancer prevention and control practitioners and used adaptive spatial filtering to create maps that show continuous surface representations of the proportion of all colorectal cancer cases diagnosed in the late stage. We also created maps that show the incidence of colorectal cancer.

Results: Our maps show distinct patterns of cancer and its relationship to community context. The maps are available to the public on the Internet and through the activities of Iowa Consortium for Comprehensive Cancer Control partners.

Conclusion: Community-participatory approaches to research are becoming more common, as are the availability of geocoded data and the use of geographic information systems to map disease. If researchers and practitioners are to engage communities in exploring cancer rates, maps should be made that accurately represent and contextualize cancer in such a way as to be useful to people familiar with the characteristics of their local areas.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2644580PMC
January 2009
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