Kirsten M. M. Beyer

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

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.

Rural Disparity in Domestic Violence Prevalence and Access to Resources

OBJECTIVE Intimate partner violence (IPV) against women is a significant health issue in the United States and worldwide. The majority of studies on IPV have been conducted in urban populations. The objectives of this study are to determine if prevalence, frequency, and severity of IPV differ by rurality and to identify variance in geographic access to IPV resources. METHODS A cross-sectional clinic-based survey of 1478 women was conducted to measure the 1-year prevalence of physical, sexual, and psychologic IPV. IPV intervention programs in the state were inventoried and mapped, and the distance to the closest program was estimated for each participant based on an innovative algorithm developed for use when only ZIP code location is available. RESULTS Women in small rural and isolated areas reported the highest prevalence of IPV (22.5% and 17.9%, respectively) compared to 15.5% for urban women. Rural women reported significantly higher severity of physical abuse than their urban counterparts. The mean distance to the nearest IPV resource was three times greater for rural women than for urban women, and rural IPV programs served more counties and had fewer on-site shelter services. Over 25% of women in small rural and isolated areas lived >40 miles from the closest program, compared with <1% of women living in urban areas. CONCLUSIONS Rural women experience higher rates of IPV and greater frequency and severity of physical abuse yet live much farther away from available resources. More IPV resources and interventions targeting rural women are needed.

Neighborhood Environment and Intimate Partner Violence A Systematic Review

Intimate partner violence (IPV) is an important global public health problem, affecting women across the life span and increasing risk for a number of unfavorable health outcomes. Typically conceptualized as a private form of violence, most research has focused on individual-level risk markers. Recently, more scholarly attention has been paid to the role that the residential neighborhood environment may play in influencing the occurrence of IPV. With research accumulating since the 1990s, increasing prominence of the topic, and no comprehensive literature reviews yet undertaken, it is time to take stock of what is known, what remains unknown, and the methods and concepts investigators have considered. In this article, we undertake a comprehensive, systematic review of the literature to date on the relationship between neighborhood environment and IPV, asking, “what is the status of scholarship related to the association between neighborhood environment and IPV occurrence?” Although the literature is young, it is receiving increasing attention from researchers in sociology, public health, criminology, and other fields. Obvious gaps in the literature include limited consideration of nonurban areas, limited theoretical motivation, and limited consideration of the range of potential contributors to environmental effects on IPV—such as built environmental factors or access to services. In addition, explanations of the pathways by which place influences the occurrence of IPV draw mainly from social disorganization theory that was developed in urban settings in the United States and may need to be adapted, especially to be useful in explaining residential environmental correlates of IPV in rural or non-U.S. settings. A more complete theoretical understanding of the relationship between neighborhood environment and IPV, especially considering differences among urban, semiurban, and rural settings and developed and developing country settings, will be necessary to advance research questions and improve policy and intervention responses to reduce the burden of IPV.

Mapping cancer for community engagement.

Following the discovery in 1987 that the previously uncharacterized endothelium derived relaxing factor was nitric oxide, there has been an explosion of interest in this molecule. This free radical gained further importance in respiratory medicine following the observation by Gustafsson, et al.1 that endogenous nitric oxide can be measured in exhaled air; subsequently, it was found that levels are high in asthma2 and fall after steroid use.3 Since then over 1600 articles have been published on nitric oxide and asthma, yet we still do not know whether using measurements of the fraction of nitric oxide in exhaled air (FENO) is of practical benefit. In this issue of Chronic Respiratory Disease, Rodway, et al. provide us with an excellent reminder of the current evidence for using (or not) FENO measurements in the diagnosis and management of asthma. Several themes emerge which are worth discussing in more detail. First, the original studies on FENO used flows (and occasionally collection methods) which differ from the most recent studies. Althoughorganizations recommendedusing different flows to measure FENO, most authors opted for a flow of 250 mL/s; this was later changed to 50 mL/s in subsequent guidelines6; however, much of the data validating FENO against other markers of airway inflammation used 250 mL/s.7,8 Approaches using different flows, calculating “alveolar” and “bronchial” nitric oxide,9 or adapting the flow to different patient populations may yield superior results. Second, there is a population of patients who have persistently high FENO and a low induced sputum eosinophil count.10 As differential eosinophil counts have been considered the gold standard for monitoring airway inflammation in asthma, with studies showing a reduction in asthma exacerbations,11,12 the existence of a population of patients who appear to have discordant FENO and eosinophil counts is troublesome. In the largest study to date comparing FENO with asthma guidelines, there was no reduction in net steroid use or exacerbations, possibly because of this discordant group.10 Further work is needed to explain this discordance; possibilities include atopy and allergy, nasal polyps, or genotypic variance in nitric oxide synthesis.13 Third, the use of FENO may depend upon the clinical question asked. Studies in asthma have examined using FENO measurements to step down inhaled corticosteroid dose following a period of dose optimization,14 or have used a step up/down approach mirroring current asthma guidelines.10 Different approaches using FENO measurements may be needed. In their article, Rodway, et al. suggest that FENO could be used as an exclusionary test for asthma. This idea is appealing, given the difficulties in diagnosing asthma correctly using tests of airflow obstruction.15,16 Using FENO as a negative predictive test for asthma, as d-dimer is used in venous thrombosis, may be a sensible approach. Interestingly, the opposite side of this argument has been examined before; Smith, et al.17 used FENO as a marker of steroid response in 52 patients presenting with undiagnosed respiratory symptoms in a single-blind, fixed-sequence, placebo-controlled trial of inhaled fluticasone. Steroid response was significantly greater in the highest FENO tertile (>47 ppb) for each endpoint. This outcome was independent of the diagnostic label. This novel approach also seems reasonable given there is a range in obstructive airway disease; some patients have eosinophilic and potentially steroid responsive lung disease,18 whereas others have steroid unresponsive neutrophilic asthma.19 If a noninvasive marker of airway inflammation could Chronic Respiratory Disease 2009; 6: 3–4Introduction 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.

Green Space, Violence, and Crime A Systematic Review

Purpose: To determine the state of evidence on relationships among urban green space, violence, and crime in the United States. Methods and Results: Major bibliographic databases were searched for studies meeting inclusion criteria. Additional studies were culled from study references and authors’ personal collections. Comparison among studies was limited by variations in study design and measurement and results were mixed. However, more evidence supports the positive impact of green space on violence and crime, indicating great potential for green space to shape health-promoting environments. Conclusion: Numerous factors influence the relationships among green space, crime, and violence. Additional research and standardization among research studies are needed to better understand these relationships.

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

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.

Revisiting exposure: Fatal and non-fatal traffic injury risk across different populations of travelers in Wisconsin, 2001-2009

Comparing the injury risk of different travel modes requires using a travel-based measure of exposure. In this study we quantify injury risk by travel mode, age, race/ethnicity, sex, and injury severity using three different travel-based exposure measures (person-trips, person-minutes of travel, and person-miles of travel) to learn how these metrics affect the characterization of risk across populations. We used a linked database of hospital and police records to identify non-fatal injuries (2001-2009), the Fatality Analysis Reporting System for fatalities (2001-2009), and the 2001 Wisconsin Add-On to the National Household Travel Survey for exposure measures. In Wisconsin, bicyclists and pedestrians have a moderately higher injury risk compared to motor vehicle occupants (adjusting for demographic factors), but the risk is much higher when exposure is measured in distance. Although the analysis did not control for socio-economic status (a likely confounder) it showed that American Indian and Black travelers in Wisconsin face higher transportation injury risk than White travelers (adjusting for sex and travel mode), across all three measures of exposure. Working with multiple metrics to form comprehensive injury risk profiles such as this one can inform decision making about how to prioritize investments in transportation injury prevention.

Disease Maps as Context for Community Mapping: A Methodological Approach for Linking Confidential Health Information with Local Geographical Knowledge for Community Health Research

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.

Five Essential Properties of Disease Maps

We argue that as the disease map user group grows, disease maps must prioritize several essential properties that support public health uses of disease maps. We identify and describe five important properties of disease maps that will produce maps appropriate for public health purposes: (1) Control the population basis of spatial support for estimating rates, (2) display rates continuously through space, (3) provide maximum geographic detail across the map, (4) consider directly and indirectly age–sex-adjusted rates, and (5) visualize rates within a relevant place context. We present an approach to realize these properties and illustrate it with small-area data from a population-based cancer registry. Users whose interests are in selecting areas for interventions to improve the health of local populations will find maps with these five properties useful. We discuss benefits and limitations of our approach, as well as future logical extensions of this work.

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

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.